Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93613 billed for date of service January 30, 
2023. 
 You asked the Plan to pay for procedure code 93613. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 93613 is bundled into payment for code 
93656. 
 
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 93613 
is a column II code to column I code 93656. This claim 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 code 93613 billed for date of service January 30, 
2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for an occlusal guard (D9944) provided on March 29, 2023. 
 
You asked the Plan to pay for the occlusal guard. You say that the night guard is medically necessary for their 
medical diagnosis. The Plan denied your request. The Plan says that the denial of payment for this item is 
correct, because the enrollee did not meet the Medicare guidelines. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers treatment for TMJ syndrome only 
when the condition or symptom is medical in nature. The treatment must also be medically reasonable and 
necessary.  
 
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 pay for the occlusal guard. Our reviewer says that 
the item is medically necessary. Our physician reviewer found that the documentation provided appears to 
address the allergic reaction to the previous appliance via narrative and photographs. An allergic reaction is a 
medical condition. It is medically reasonable and necessary to provide the enrollee with an alternate appliance 
which is free of the offending allergen to treat the enrollee's condition. 
 
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 occlusal guard have been met. Therefore, we decided that the Plan has to 
pay for an occlusal guard (D9944) provided on March 29, 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 procedure code 84480 billed for date of service June 21, 
2023.  

You asked the Plan to pay for procedure code 84480. You say that this testing was necessary and is supported 
in the medical record. The Plan denied your request. The Plan says payment for code 84480 is bundled into 
payment for code 84481. 
 
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 84480 
is a column two code to column one code 84481 with a modifier indicator of 0. The column two code is 
therefore not payable. 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 84480 billed for date of service June 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for over-the-counter COVID-19 test kits provided on June 26, 
2023. 
 
You asked the Plan to pay for over-the-counter COVID-19 test kits provided on. You say that you would like a 
prompt review of this appeal and approval of this approved service. The Plan denied your request. The Plan 
says over the counter (OTC) COVID-19 tests are not covered by Medicare after May 11, 2023. 
 The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and over-the-
counter COVID-19 test kits is an OTC item. The Plan does not offer coverage for OTC items, which includes 
COVID-19 test kits. Therefore, we decided that the Plan does not have to pay for over-the-counter COVID-19 
test kits provided on June 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7. 
 
You asked the Plan to pre-approve the Dexcom G7. You say that the enrollee has been receiving samples of the 
product and have submitted the fill history. The Plan denied your request. The Plan says the medical records 
submitted do not establish that the Dexcom G7 CGM sensor is reasonable and necessary.  
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
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 Dexcom G7. Our reviewer says that 
this item is not medically necessary. Our physician reviewer found coverage criteria for CGM require insulin 
use or low blood glucose sugar. The enrollee is not having low blood glucose sugar we are told of nor on a 
medication that typically causes low blood glucose sugar. Although the CGM may be helping the enrollee's 
blood glucose control and diet, coverage criteria are not met. 
 
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 Dexcom G7. have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Dexcom G7.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on August 11, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that these services were provided to the enrollee. The 
Plan denied your request. The Plan says these services were billed incorrectly. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on August 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an in-network exception for an office visit to be 
provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve an in-network exception. You say that these services are necessary. The 
Plan denied your request. The Plan says their decision to deny an in-network exception was correct. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that you can choose to receive care from out-of-network providers. However, if you use an out-of-
network provider, your share of the costs for your covered services may be higher. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve an in-network exception for these items/services. Therefore, we decided that the Plan 
does not have to pre-approve an in-network exception for an office visit to be provided by an out-of-network 
(OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and two or more power seating system motors (E2311), a harness (E2313), an expandable controller (E2377) 
and an attendant control (E2331). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that you disagree with the denial. The Plan 
denied your request. The Plan says Medicare guidance says the upgraded electronics are not medically 
necessary. An attendant control cannot be covered if a user-operated control is requested. 
 
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 wheelchair accessories. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has hemiplegia. The enrollee has a functional contralateral extremity. Per 
Social Security Administration (SSA) 1862 (a)1(A), the enrollee has adequate strength to manage standard 
power drives. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wheelchair accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection between wheelchair controller and two or more power 
seating system motors (E2311), a harness (E2313), an expandable controller (E2377) and an attendant control 
(E2331).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for DecisionDx-SCC testing (0315U) provided on May 17, 
2023. 
 
You asked the Plan to pay for DecisionDx-SCC testing. You say that this test was necessary and is supported in 
the medical record. The Plan denied your request. The Plan says this test is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. Once this is complete, the test is assigned a 
reimbursement rate and a unique test identifier. 
 We looked at the file and Medicare rules. This test is listed in the DEX database as non-covered. This 
determination was made and is specific to the test at issue. Based on this information, we decided that 
Medicare rules for coverage of DecisionDx-SCC testing have not been met. Therefore, we decided that the 
Plan does not have to pay for DecisionDx-SCC testing (0315U) provided on May 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 17, 2021. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says this claim 
was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the laboratory services was not filed until May 25, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the laboratory services provided on September 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xeljanz XR. 
 
You asked the Plan to pre-approve the medication. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xeljanz XR.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for Medicare Part B drug injections and 
specialist visits provided on June 22, 2023, and June 29, 2023. 
 
You asked the Plan to waive the cost share for Medicare Part B drug injections and specialist visits. You say 
that the previous injections had a lower cost share. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B prescription drugs and a $25 copayment for each specialist visit.   You have been asked to pay $369.68 for Medicare Part B drug injections and specialist visits. This total 
includes $159.84 coinsurance, which is 20% of the allowed amount for each Medicare Part B drug injection 
($799.20 allowed x 20% = $159.84 per injection x 2 injections = $319.68) and a $25 copayment per specialist 
visit ($25 per visit x 2 visits = $50). The injections fall within the Medicare Part B prescription drugs benefit 
category. The specialist visits fall within the physician/practitioner 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. Therefore, we decided that the Plan 
does not have to waive the cost share for Medicare Part B drug injections and specialist visits provided on June 
22, 2023, and June 29, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the IDGenetix test (81479). 
 
You asked the Plan to pre-approve the genetic testing. You say that the IDGenetix test is medically necessary, 
and the results directly impact patient care. The Plan denied your request. The Plan says this test is not covered 
by Medicare and is not FDA approved 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 We looked at the file, and Medicare rules. The IDGenetix test is not located in the DEX Diagnostic Exchange 
Registry. This test is not FDA approved or satisfactorily completed a Technical Assessment by Molecular 
Diagnostic Services Program. Based on this information, we decided that Medicare rules for coverage of the 
genetic testing have not been met. Therefore, we decided that the Plan does not have to pre-approve the 
IDGenetix test (81479).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for annual depression screening provided on July 11, 2023. 
 
You asked the Plan to pay for annual depression screening. You say that you are requesting reconsideration for 
the denied claim. The Plan denied your request. The Plan says they cover one screening for depression per 
year. 
 
The Plan must follow Medicare rules. Medicare rules say that effective for claims with dates of service on or 
after October 14, 2011, CMS will cover annual screening up to 15 minutes for Medicare beneficiaries when 
staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-
up. At a minimum level, staff-assisted supports consist of clinical staff (e.g., nurse, physician assistant) in the 
primary care setting who can advise the physician of screening results and who can facilitate and coordinate 
referrals to mental health treatment. Screening for depression is non-covered when performed more than one 
time in a 12-month period. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of annual depression screening have not been met. Therefore, we decided that the Plan does not have 
to pay for annual depression screening provided on July 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) and a core build-up (D2950) for tooth 
#18. 
 
You asked the Plan to pre-approve D2740 and D2950. You say that you had a root canal but now you need a 
crown. The Plan denied your request. The Plan says this dental work has been correctly denied. 
 
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 Plan covers D2740 and 
D2950 when the services are medically necessary and reasonable.  
 
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 D2740 and D2950. Our reviewer says 
that D2740 and D2950 are not medically necessary. Our physician reviewer found based on the medical 
records provided the root canal may need to be re-done prior to placing a buildup and a crown.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of D2740 and D2950 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a crown (D2740) and a core build-up (D2950) for tooth #18.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on August 25, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that these services were provided to the enrollee. The 
Plan denied your request. The Plan says these services were billed incorrectly. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on August 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99306 billed for date of service July 21, 
2023.  
 
You asked the Plan to pay for procedure code 99306. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.   
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 99306 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 99306 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99306 billed for date of service July 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on August 17, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that these services were provided to the enrollee. The 
Plan denied your request. The Plan says these services were billed incorrectly. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on August 17, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on October 6, 2022, to 
October 9, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that J96.01 
is supported in the documentation, therefore the claim should be paid at the DRG originally billed. The Plan 
denied your request. The Plan says J96.01 is not supported in the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code J96.01, defined as acute 
respiratory failure with hypoxia. 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 pay for the inpatient 
hospital services at the DRG originally billed. Our reviewer says that secondary diagnosis J96.01 is not 
supported in the documentation. Our physician reviewer found the enrollee presented with respiratory 
symptoms and was found to have Influenza A. Mild hypoxia was present, which is not unusual with any 
respiratory illness. There is no evidence, however, that the enrollee had respiratory failure. They were never 
tachypneic or noted to be in respiratory distress. Their lungs were always clear to auscultation.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on October 6, 2022, to October 9, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power mobility device (PMD). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the submitted records do not support that the enrollee requires a power mobility device to perform self-care in the home. The criteria for coverage 
are not met and the PMD is not reasonable or medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power mobility device (PMD).