Persius/hicric huggingface dataset:
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 93005, 94640, and 94640-76 billed for date of service 
June 9, 2023. 
 
You asked the Plan to pay for codes 93005, 94640, and 94640-76. You say that these are payable codes. The 
Plan denied your request. The Plan says these codes are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that STV-packaged services are services for which separate 
payment is made only if there is no service with status indicator S, T, or V reported on the same claim. If a 
claim includes a service that is assigned status indicator S, T, or V reported on the same claim as the STV- 
packaged service, the payment for the STV-packaged service is packaged into the payment for the service(s) 
with status indicator S, T, V and no separate payment is made for the STV-packaged service. STV-packaged 
services are assigned status indicator Q1. In this case, the codes in dispute have a status indicator of QI, meaning that they are STV-packaged services.  These disputed codes were billed on the same claim with a code 
that has a status indicator of S, T, or V.  This means that the codes in dispute in this appeal are not separately 
payable. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of codes 93005, 94640, and 94640-76 have not been met. Therefore, we decided that the Plan does 
not have to pay for codes 93005, 94640, and 94640-76 billed for date of service June 9, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Actemra. 
 You asked the Plan to pre-approve Actemra. You say that Actemra is the only drug that works for both 
polymyalgia rheumatica and seronegative rheumatoid arthritis. The Plan denied your request. The Plan says the 
enrollee has not tried the preferred drugs.  
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Actemra. Our physician reviewer found 
that Actemra is being requested to treat rheumatoid arthritis. The Plan requires a trial of Remicade, Inflectra, 
Infliximab, or Simponi Aria before they will approve the requested drug. In this case, the enrollee has not tried 
and failed the required drugs. There is no documentation provided indicating that the Plans required drugs 
would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Actemra have been met. Therefore, we decided that the Plan does not have to 
pre-approve Actemra.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on April 5, 2023, billed with 
procedure code 00731. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim is billed with an inappropriate place of 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that the place of service (POS) code is generally used 
to reflect the actual setting where the beneficiary receives the face-to-face service. 
 
We looked at the file and Medicare rules. We find that the claim was inappropriately billed with place of 
service 22 as the enrollee was registered inpatient on the date of service in question. Based on this information, 
we decided that Medicare rules for coverage of the practitioner services provided have not been met. Therefore, we decided that the Plan does not have to pay for practitioner services provided on April 5, 2023, billed with 
procedure code 00731.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Fundus photograph eye test provided on July 14, 2023, by 
an out-of-network (OON) provider.  
 
You asked the Plan to pay for an eye test. You say that this was necessary and should be covered. The Plan 
denied your request. The Plan says there was no preauthorization by a primary care provider (this is different 
than a referral) for an out-of-network (OON) provider or facility. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a Fundus photograph eye test provided on July 14, 
2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a comprehensive oral evaluation, bitewing x-rays, 
panoramic radiographic images, and cleaning (D0330, D1110, D0274, D0150) provided on July 31, 2023. 
 
You asked the Plan to pay more for the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. Additionally. your benefit for dental x-rays was exhausted on the appealed claim. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Additionally. your benefit for dental x-rays was exhausted on the appealed claim. Therefore, we decided that 
the Plan does not have to pay more for a comprehensive oral evaluation, bitewing x-rays, panoramic 
radiographic images, and cleaning (D0330, D1110, D0274, D0150) provided on July 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation, cleaning, and fillings (D2335, 
D0120, D1110) provided on July 31, 2023, to August 8, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental benefits.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a periodic oral evaluation, cleaning, and fillings (D2335, D0120, D1110) provided on July 31, 2023, 
to August 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic manipulative treatment (98940). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says you do not meet criteria for coverage of the requested 
service.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve this service. Our reviewer says that you 
do not meet criteria for coverage of the requested service. Our physician reviewer found that in this case, the 
record indicates that you have chronic back pain from a spinal subluxation. The record provided documents 
that this is a chronic condition and does not document acute exacerbation. The record provided supports that 
the requested service is maintenance care and does not establish the medical necessity and reasonableness, as 
defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The 
requested service is not recommended. 
  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve chiropractic manipulative treatment (98940).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81479) provided on September 8, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim for this molecular pathology testing did not include the required 
unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the lab services have 
not been met. Therefore, we decided that the Plan does not have to pay for lab services (81479) provided on 
September 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a comprehensive oral evaluation, intraoral 
x-rays, and panoramic radiographic images (D0150, D0210, D0330) provided on July 11, 2023. 
 
You asked the Plan to waive the coinsurance for the dental services. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. Your benefit for dental x-rays was exhausted on the appealed claim. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  You have been asked to pay a 30% coinsurance for an out-of-network oral exam and intraoral x-rays. These 
services fall within the dental services benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Your benefit for dental x-rays was exhausted on the appealed claim. Therefore, 
we decided that the Plan does not have to waive the coinsurance for a comprehensive oral evaluation, intraoral 
x-rays, and panoramic radiographic images (D0150, D0210, D0330) provided on July 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the localized delivery of antimicrobial 
agents (D4381 x 2) provided on March 30, 2023 and April 4, 2023. 
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these services are 
not covered under the supplemental dental policy.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the services provided are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to issue reimbursement for 
the localized delivery of antimicrobial agents (D4381 x 2) provided on March 30, 2023 and April 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D3428, D3430, D3425, and D3426) on 
August 21, 2023. 
 
You asked the Plan to pay for the dental services (D3428, D3430, D3425, and D3426). You say that you would 
like to request reconsideration for payment. The Plan denied your request. The Plan says the services requested 
are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental 
services (D3428, D3430, D3425, and D3426) on August 21, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous LAA closure.   
You asked the Plan to pre-approve a percutaneous LAA closure. You say that the enrollee is scheduled for an 
inpatient procedure on December 12, 2023. The Plan denied your request. The Plan says a percutaneous LAA 
closure is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that LAAC devices are covered when the device has 
received Food and Drug Administration (FDA) Premarket Approval (PMA) for that devices FDA-approved 
indication and meet all of the conditions.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a percutaneous LAA closure. Our 
reviewer says that a percutaneous LAA closure is not medically necessary. Our physician reviewer found that 
there is no documentation of performance of an evidence-based shared decision-making interaction on 
anticoagulation. Therefore, a LAAC placement would not be considered reasonable or medically necessary in 
the enrollee's clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a percutaneous LAA closure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a percutaneous LAA closure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the tuberculosis test provided by an in-
network provider on September 5, 2023. 
 
You asked the Plan to waive the deductible for the tuberculosis test. You say that you do not agree with the 
cost sharing. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $525 in-network deductible which applies to in-network lab services. 
 
You have been asked to pay a $61.98 deductible for the tuberculosis test. The item or service you asked the 
Plan to waive the deductible for falls within the outpatient diagnostic tests and therapeutic services and supplies 
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $525 
in-network deductible which applies to outpatient diagnostic tests and therapeutic services and supplies. This 
cost sharing is a contractual obligation that had not been met at the time the tuberculosis test was received on 
September 5, 2023. Therefore, we decided that the Plan does not have to waive the deductible for the 
tuberculosis test provided by an in-network provider on September 5, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the kyphoplasty procedure. 
 
You asked the Plan to pre-approve the kyphoplasty procedure. The Plan denied your request. The Plan says the 
kyphoplasty procedure is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the kyphoplasty procedure. Our 
reviewer says that the kyphoplasty procedure is not medically necessary. Our physician reviewer found that the 
documentation is not evident regarding acute or subacute fractures as the enrollee notes the pain has been 
ongoing for six months. Also, there is no documentation of a progression of the body height loss, kyphotic 
deformity, or a severe impact on daily activities. However, there is a magnetic resonance imaging (MRI) 
corroboration of the plausible causes of pain. Therefore, the enrollee does not meet the LCD coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the kyphoplasty procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the kyphoplasty procedure.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the second unit of procedure code L8000 provided on January 25, 
2023. 
 
You asked the Plan to pay for the second unit of procedure code L8000. You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says that this claim is a duplicate 
of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. We find that the file does not include sufficient evidence to support 
the Plans argument that the claim at issue is a duplicate. We find that the records clearly show that two 
different colored mastectomy bras were delivered. Additionally, we received a corrected proof of delivery with 
the correct units and item number. Based on this information, we decided that Medicare rules for coverage of 
the second unit of procedure code L8000 have been met. Therefore, we decided that the Plan has to pay for the 
second unit of procedure code L8000 provided on January 25, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the general health panel (80050) provided on January 6, 
2023. 
 
You asked the Plan to pay for the general health panel. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is considered a non-
covered code. 
 
You have requested payment for services billed under code 80050. Medicare does not cover or pay for services 
billed under this code. Therefore, we decided that the Plan does not have to pay for the general health panel 
(80050) provided on January 6, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-Syn-3 (J7328). 
 You asked the Plan to pre-approve Gel-Syn-3. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the member has not tried and failed one of the preferred step therapy 
(multi-injection) devices: Orthovisc or Supartz FX. The Plan also says there is no indication the preferred drugs 
would likely be less effective, and/or cause adverse effects for the member.  
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Gel-Syn-3. Our reviewer says that the 
enrollee does not meet the criteria for the requested drugs. Our physician reviewer found the Plan requires a 
trial of Orthovisc or Supartz FX before they will approve the requested drug. In this case, the patient has not 
tried and failed the required drugs. Our physician reviewer also found there is no documentation provided 
indicating that the plans required drugs would likely be less effective and/or likely have adverse effects for the 
enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gel-Syn-3 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Gel-Syn-3 (J7328).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D5110 and D5214) on April 13, 2023. 
 
You asked the Plan to pay for the dental services (D5110 and D5214). You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 13, 2023. 
Therefore, we decided that the Plan does not have to pay for the dental services (D5110 and D5214) on April 
13, 2023.