Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ischial containment (L5649), flexible inner socket 
(L5651), and replacement, socket, above knee/knee disarticulation (L5701) to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve an ischial containment, flexible inner socket, and replacement socket. You 
say that you need a replacement prosthetic leg because the residual limb length and shape have changed, and 
you can no longer wear your current prosthesis. The Plan denied your request. The Plan says the requested 
provider is not contracted in your network. The Plan also says there are no extenuating circumstances related to 
geographic access, compelling continuity of care making it medically necessary that future care come only 
from this provider to justify prior authorization of OON benefits. 
 
 
 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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 these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an ischial containment (L5649), flexible inner socket (L5651), and replacement, socket, above knee/knee 
disarticulation (L5701) to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodic oral evaluation - established patient (D0120) and 
periodontal maintenance (D4910) provided on August 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that prior to your appointment you called the Plan, 
and you were told the services would be covered. 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. This benefit includes the 
requested periodic oral evaluation - established patient (D0120) but is limited to one every six months, either 
D0120 or D0150. Periodontal maintenance (D4910) is not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D4910 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for periodontal 
maintenance (D4910) provided on August 8, 2022. 
 
We looked at the file, the Plans rules, and Medicares rules. You previously received covered comprehensive 
oral evaluation - new or established patient (D0150) on February 21, 2022. Although these are two different 
services, they fall within the same category in your Evidence of Coverage and are subject to the same 
frequency limitations. Therefore, this benefit was exhausted as of August 8, 2022. Therefore, we decided that 
the Plan does not have to pay for periodic oral evaluation - established patient (D0120) provided on August 8, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom breast prosthesis (L8035). 
 
You asked the Plan to pre-approve a custom breast prosthesis. You say that this is necessary. The Plan denied 
your request. The Plan says this is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that the medical necessity for the additional features 
of a custom fabricated prosthesis (L8035) compared to a prefabricated silicone breast prosthesis has not been 
established, and therefore, if an L8035 breast prosthesis is billed, it will be denied as not reasonable and 
necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a custom breast prosthesis have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a custom breast prosthesis (L8035).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) of the heart with quantitative 
calcium scoring (75571) provided on December 14, 2022. 
 
You asked the Plan to pay for the CT of the heart with quantitative calcium scoring. You say that you would 
like this claim to be reprocessed for payment. The Plan denied your request. The Plan says Medicare does not 
cover a screening coronary computed tomography angiography (CCTA) for asymptomatic patients, for risk 
stratification or for quantitative evaluation of coronary calcium. 
 
The Plan follows Medicare rules. Medicare rules say that the test is never covered for screening, i.e., in the 
absence of signs, symptoms or disease. 
 
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 CT of the heart with quantitative calcium 
scoring. Our reviewer says that the enrollee did not meet the coverage criteria for the CT of the heart with 
quantitative calcium scoring. Our physician reviewer found the enrollee has no documented cardiac symptoms. 
Centers for Medicare & Medicaid Services (CMS) does not allow CT coronary scoring as a screening tool in 
asymptomatic patients or in patients without a calculated lifetime risk of atherosclerotic cardiovascular disease 
of 9% to 19%. Our reviewer also found that this exam should be denied as a non-covered benefit. 
 
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 CT of the heart with quantitative calcium scoring have not been met. 
Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) of the heart with 
quantitative calcium scoring (75571) provided on December 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic CGM. 
 
You asked the Plan to pre-approve therapeutic CGM. You say that you feel the therapeutic CGM would be 
beneficial to the enrollee. The Plan denied your request. The Plan says the enrollee does not require insulin 
three or more times daily. 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve 
therapeutic CGM.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 
29, 2022. 
 You asked the Plan to pay for procedure code 70450. You say that the member had multiple exams done on 
this date of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into 
payment for code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service November 29, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the external counterpulsation (G0166) provided on August 
30, 2022. 
 
You asked the Plan to pay for the outpatient service. You say that the billed code does not have any diagnosis 
restrictions. The Plan denied your request. The Plan says there was no documentation provided to support the 
billed service. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the outpatient service have been met. 
Specifically, there were no records provided to support the billed service. Without this information, we cannot 
determine if the services were medically necessary. The record shows that the Plan requested this information, 
but none was provided. Therefore, we decided that the Plan does not have to pay for the external 
counterpulsation (G0166) provided on August 30, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each cardiac rehabilitation service provided 
on October 03, 2022, to October 31, 2022. 
 
You asked the Plan to waive the copayment for each cardiac rehabilitation service. You say that you were not 
aware you would have a copayment. 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 a $30 
copayment for in-network cardiac rehabilitation services. 
 
You have been asked to pay a $30 copayment for each cardiac rehabilitation service. This item/service falls 
within the in-network cardiac rehabilitation 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. The total amount you owe is $360 ($30 copayment x 12 visits = 
$360). Therefore, we decided that the Plan does not have to waive the copayment for each cardiac 
rehabilitation service provided on October 03, 2022, to October 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the neurosurgery services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the neurosurgery services. You say that the service is medically necessary. 
The Plan denied your request. The Plan says there are in-network providers available to perform this service. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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 these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the neurosurgery services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the syringe (A4657), injection (J1644), dialysis procedure 
(90999), assay of urea nitrogen (84520), and hemoglobin (85018), provided on August 3, 2021, through August 
31, 2021. 
 
You asked the Plan to pay for the physician services. You say that the services should be covered. The Plan 
denied your request. The Plan says the claim was filed untimely. 
 
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 physician services was not filed until January 21, 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 syringe (A4657), injection (J1644), dialysis procedure 
(90999), assay of urea nitrogen (84520), and hemoglobin (85018), provided on August 3, 2021, through August 
31, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a VASS vacuum socket (L5781). 
 
You asked the Plan to pre-approve a VASS vacuum socket. The Plan denied your request. The Plan says 
Medicare Guidance says experimental items and items that are not shown to be safe and effective cannot be 
covered. 
 
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 VASS vacuum socket. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the provided medical notes indicate an elevated vacuum system is recommended.  
The literature reviewed indicates that further research is needed with clinical trials that recruit larger sample 
sizes and report long-term outcome data for the requested vacuum suspension system. Thus, the requested device is not considered medically necessary. 
 
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 VASS vacuum socket have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a VASS vacuum socket (L5781).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99223 billed for date of service January 17, 2023. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says that an 
observation code needs to be billed. 
 
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 99223 is initial hospital inpatient or observation care, per 
day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making.  
 
We find that CPT code 99223 is a billable code for either inpatient or observation services. Based on this 
information, we decided that Medicare rules for coverage of the billed services have been met. Therefore, we 
decided that the Plan has to pay for procedure code 99223 billed for date of service January 17, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implantation or replacement of Carotid Sinus 
Baroreflex Activation Device (0266T). 
 
You asked the Plan to pre-approve the implantation or replacement of Carotid Sinus Baroreflex Activation 
Device. You say that the service is medically necessary. The Plan denied your request. The Plan says this 
service is considered experimental. 
 
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 implantation or replacement of 
Carotid Sinus Baroreflex Activation Device. Our reviewer says that the requested service is not considered 
medically reasonable and necessary in this case. Our physician reviewer found this service is considered 
experimental.  
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 implantation or replacement of Carotid Sinus Baroreflex Activation Device 
have not been met. Therefore, we decided that the Plan does not have to pre-approve the implantation or 
replacement of Carotid Sinus Baroreflex Activation Device (0266T).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oral hygiene instructions (D1330) provided on January 24, 
2023. 
 
You asked the Plan to pay for dental services. You say that you should not have to pay for this service because 
you were told a deep cleaning was all covered. The Plan denied your request. The Plan says this service is not 
covered under your 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. Oral hygiene instructions 
(D1330) is not covered under the Plans dental benefits. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D1330 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for oral hygiene 
instructions (D1330) provided on January 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and an extraction (D7140) 
for tooth #15 provided by an out-of-network provider on December 1, 2021. 
 
You asked the Plan to pay for the dental services. You say that you filed for reimbursement on time, and it was 
never processed. 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. Also, it was verified that you were told 
the rendering provider was an out-of-network provider and services would not be covered by 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. 
 
  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 limited oral evaluation (D0140) and an extraction (D7140) for tooth #15 provided by an out-of-
network provider on December 1, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99285) provided on November 28, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says code 99285 is 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 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. Counseling and/or coordination of care with 
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature 
of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function". 
 
We asked our coder 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 services. Our reviewer says that the use of code 99285 is 
not supported by the records provided. Our reviewer found that there was no medical decision making of high 
complexity or counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies provided consistent with the nature of the problem(s) and the patient's and/or family's 
needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life 
or physiologic function. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (99285) provided on November 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service December 5, 2022. 
 
You asked the Plan to pay for the billed services. You say that the medical records support the charges. 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. A 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 billed 
services have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing billed 
for date of service December 5, 2022.