Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy visits x7 and occupational therapy 
visits x4. 
 
You asked the Plan to pre-approve physical therapy visits x8 and occupational therapy visits x4. You say that 
the requested services are medically necessary. The Plan denied your request. The Plan says the number of 
visits requested are not medically necessary. One physical therapy visit has been approved for your discharge 
to a home or outpatient exercise program. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that the 
enrollee is no longer home bound and remained unable to change functional stats with activities of daily living 
(ADLs) six months post stroke. The enrollee is ambulating at a community level. The enrollee does not require 
continued skilled services to address ADL status. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve physical therapy visits x7 and occupational therapy visits x4.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the endodontic therapy (D3320) for tooth #12 and to 
pay for the cone beam (D0364) provided by an out-of-network provider on April 5, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you should be covered 100% for x-rays 
and for out-of-network dental services. 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. Also, the cone beam is not covered by the Plan. 
 
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 total amount billed for the endodontic therapy (D3320) was $1,449 and the total allowed amount was $456 
leaving a difference of $993 ($1,449 billed - $456 allowed). 
 
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. The 
cone beam is not covered under the Plans dental benefit. Therefore, we decided that the Plan does not have to 
pay more for the endodontic therapy (D3320) for tooth #12 and to pay for the cone beam (D0364) provided by 
an out-of-network provider on April 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481 and 87653 billed for date of service 
February 28, 2023. 
 
You asked the Plan to pay for procedure codes 87481 and 87653. You say that medical records were submitted 
for review. The Plan denied your request. The Plan says payment for codes 87481 and 87653 are bundled into 
payment for code 87801. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
In this case, we have confirmed that codes 87481 and 87653 are a column II codes to column I code 87801. 
Codes 87481 and 87653 were billed with the XU modifier. The records provided do not show that these 
services were unusual, non-overlapping services. Based on the claim submitted, Medicare billing criteria have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 87481 and 87653 
billed for date of service February 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a determination of refractive state (92015) provided on 
January 24, 2023. 
 
You asked the Plan to pay for a determination of refractive state (92015). You say that you were seen for a 
routine eye examination with this provider. The Plan denied your request. The Plan says the refractive exam is 
denied stating the patients coverage does not provide for this service. The Plan also says that a routine 
refraction is considered part of a routine eye exam and not payable separately. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when the eye refraction is part of a routine eye examination. 
 
We looked at the file and the Plan's rules. The Plan rules say that original Medicare does not cover routine eye 
examinations (eye refractions) for eyeglasses/contacts. The Plan contract also says that they cover one routine 
eye examination, including refraction every calendar year. The record shows the refraction was part of a 
medical/diagnostic examination. Based on this information, we decided that the Plan's rules for coverage of a 
determination of refractive state (92015) have not been met. Therefore, we decided that the Plan does not have 
to pay for a determination of refractive state (92015) provided on January 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service December 
21, 2022. 
 
You asked the Plan to pay for procedure code 99053. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says procedure code 99053 is considered bundled and not 
separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service December 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a cleaning, periodic oral evaluation, application of 
fluoride, and sales tax (D1206, D9985, D0120, D1110) provided on March 17, 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 charges. 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.  
 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. 
Medicare does not make separate payment for sales tax. Therefore, we decided that the Plan does not have to 
pay more for a cleaning, periodic oral evaluation, application of fluoride, and sales tax (D1206, D9985, D0120, 
D1110) provided on March 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code G0452 for date of service July 19, 2022. 
 
You asked the Plan to pay for code G0452. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services billed are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code G0452 is molecular pathology procedure; physician 
interpretation and report. 
 
We find that CPT code G0452 is not supported in the medical record. Specifically, the documentation did not 
include detailed notes in order to determine that interpretation and report of the molecular pathology was 
performed. Based on this information, we decided that Medicare rules for coverage of code G0452 have not 
been met. Therefore, we decided that the Plan does not have to pay for code G0452 for date of service July 19, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve T10 kyphoplasty (22513). 
 
You asked the Plan to pre-approve T10 kyphoplasty. You say that this is medically necessary. The Plan denied 
your request. The Plan says medical necessity coverage criteria is not met as the pain is multifactorial. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be covered when specific criteria are 
met. 
 
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 T10 kyphoplasty. Our reviewer says 
that the enrollee does not meet criteria for coverage. Our physician reviewer found detailed documentation is 
not evident regarding an acute or subacute compression fracture at T10. There is no indication of a progression 
of the body height loss, worsening pain, or a severe impact on daily activities. Moreover, there is magnetic 
resonance imaging corroboration of plausible other causes of pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of T10 kyphoplasty have not been met. Therefore, we decided that the Plan does 
not have to pre-approve T10 kyphoplasty (22513).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95870-26 and 95861 billed for date of 
service June 21, 2022. 
 
You asked the Plan to pay for the billed services. You say that the services should not be bundled. The Plan 
denied your request. The Plan says the rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules say that submitted claims in 
which the unit of service exceeds the MUE value cannot be paid when the MAI value is 3, unless there is 
evidence justifying the excess units.  
 
In this case, the MUE for CPT code 95861 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. The documentation does not show that the excess units were correctly coded and 
medically necessary. Based on the claim submitted, Medicare billing criteria have not been met. 
 
In this case, we have confirmed that code 95870-26 is a column II code to column I code 95861. Code 95870-
26 has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare 
billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 
95870-26 and 95861 billed for date of service June 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says medical necessity criteria has not been met 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no magnetic resonance imaging showing only modic changes without facet 
degenerative joint disease or foraminal stenosis. The cause of pain is not clear. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure (64628, 64629).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vivigen allograft (20930). 
 
You asked the Plan to pre-approve a Vivigen allograft. You say that this is medically necessary. The Plan 
denied your request. The Plan says this 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 a Vivigen allograft. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows 
this requested allograft to be an effective and/or safe treatment for the noted pathology. Further studies are 
needed to demonstrate this request has beneficial outcomes compared with conventional treatment. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. 
 
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 Vivigen allograft have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Vivigen allograft (20930).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on December 31, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you hit a 
deer while driving and a passerby called the ambulance. You also say that you did not request or agree to the 
ambulance being called. The Plan denied your request. The Plan says these services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on December 31, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on December 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit (99202) and a determination of 
refractive state (92015) provided on January 24, 2023. 
 
You asked the Plan to pay for a specialist office visit (99202) and a determination of refractive state (92015). 
You say that you were seen for a routine eye examination. The Plan denied your request. The Plan says a 
refraction is considered part of a routine eye examination and not payable separately. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when it is a routine eye examination (eye refraction). 
 
We looked at the file and the Plan's rules. The Plan rules say that Original Medicare does not cover routine eye 
examinations (eye refractions). The record shows this was a medical/diagnostic eye examination (eye 
refraction). Based on this information, we decided that the Plan's rules for coverage of a specialist office visit 
(99202) and a determination of refractive state (92015) have not been met. Therefore, we decided that the Plan 
does not have to pay for a specialist office visit (99202) and a determination of refractive state (92015) 
provided on January 24, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transplant related transportation (S9975) provided on 
January 9, 2023. 
 
You asked the Plan to pay for the transplant related transportation. You say that the transportation was 
necessary because you needed a plastic stent removed. You also say that it was left inside you after your 
transplant, and had to be removed to save your kidney. The Plan denied your request. The Plan says this is not 
transplant related because the listed provider for date of service January 9, 2023, is not the transplant facility. 
 
The Plan must follow Medicare rules. Medicare rules say that in any circumstance in which an MA plan 
provides transplant services at a more distant location, the MA plan must provide reasonable transportation to 
the distant facility for the enrollee and a companion. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the transplant related transportation have not been met. Therefore, we decided that the Plan does 
not have to pay for the transplant related transportation (S9975) provided on January 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite-one surface, anterior (D2330) 
provided on April 12, 2023. 
 
You asked the Plan to pay for this dental item. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says your benefit for the dental item provided 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 dental item provided was exhausted on date of service November 11, 2022.  
  
 
 
 
 
Specifically, the Plans contract states that a resin-based composite-one surface, anterior is covered every six 
months. You previously received two resin-based composites-two surfaces, anterior (D2331) on November 11, 
2022, less than six months prior, which were paid for by the Plan. These are associated dental items within the 
same benefit category. Therefore, you have exhausted the allowable benefit for the dental item provided in this 
case. Therefore, we decided that the Plan does not have to pay for the resin-based composite-one surface, 
anterior (D2330) provided on April 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an implant supported crown (D6065), provided on January 4, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you needed this new crown. 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 December 3, 2020. 
Therefore, we decided that the Plan does not have to pay for an implant supported crown (D6065), provided on 
January 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) 
provided on March 29, 2023. 
 
You asked the Plan to pay for this dental item. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this dental item is not a covered benefit 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the dental item provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core buildup, 
including any pins when required (D2950) provided on March 29, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87798-XU billed for date of service January 
19, 2023. 
 
You asked the Plan to pay for procedure code 87798-XU. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says payment for code 87798 is bundled into 
payment for code 87801. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 87798 
is a column II code to column I code 87801. The code at issue was billed with the XU modifier. The records 
provided did not show the services were distinct components of the main service. Based on the claim 
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 87798-XU billed for date of service January 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the bone replacement graft (D7953) provided on April 
11, 2023. 
 
You asked the Plan to pay more for the dental service. You say that you are appealing the amount that you are 
being billed for the dental service. The Plan denied your request. The Plan says your annual dental maximum 
benefit for the year 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 the Plan paid $146 for dental services on February 14, 2023. On March 7, 2023, the Plan paid $135 for 
dental services. On April 11, 2023, the Plan paid $1,219 for dental services. For the year of 2023 the Plan paid 
$1,500 ($146 paid + $135 paid + $1,219 paid) for dental services. Therefore, your annual dental maximum 
benefit for the year of 2023 was exhausted on the date of service of April 11, 2023. Therefore, we decided that 
the Plan does not have to pay more for the bone replacement graft (D7953) provided on April 11, 2023.