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

 
We decided that the Plan does not have to pay for infusion services provided on March 21, 2023. 
 
You asked the Plan to pay for 96365-59, 96366-59, 96521, J1817, G0108. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says the records do not support any of these codes. 
 
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 96365-59 is intravenous infusion, for therapy, 
prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour. The CPT Code Manual definition of 
code 96366-59 is intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each 
additional hour. The CPT Code Manual definition of code 96521 is refilling and maintenance of portable 
pump. The CPT Code Manual definition of code J1817 is administration through durable medical equipment 
(i.e., insulin pump) per 50 units. The CPT Code Manual definition of code G0108 is diabetes outpatient self-
management training services, individual, per 30 minutes.  
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 96365-59, 96366-59, 96521, J1817, G0108. Our reviewer 
says that these codes do not meet criteria for payment. For code 96365, our reviewer found the procedure 
report describes intravenous insulin treatment for an outpatient. There is a more specific code that should be 
used. For code 96366, our reviewer found there is a more specific code that should be used. For code 96521, 
our reviewer found the medical record includes a physician order for refilling and maintenance of portable 
pump; however, it does not confirm the procedure was performed and it was not documented. Also, 
intravenous insulin treatment for an outpatient is described in the medical record, for which this code is 
inappropriate. For code J1817, our reviewer found that a more specific procedure code should be reported for 
intravenous insulin treatment for an outpatient. For code G0108, our reviewer found that the record includes 
diabetes management training services; however, this procedure is a timed code and in this case the time was 
not documented. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 96365-59, 96366-59, 96521, J1817, G0108 have not been met. Therefore, we 
decided that the Plan does not have to pay for infusion services provided on March 21, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kerecis omega3 skin substitute (Q4158, 15271, 15275). 
 
You asked the Plan to pre-approve Kerecis omega3 skin substitute. You say that this is medically necessary. 
The Plan denied your request. The Plan says this is experimental, investigational, unproven, and 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 Kerecis omega3 skin substitute. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found while Kerecis wound dressings do demonstrate some effectiveness in 
studies and in the literature with regards to wound healing, it is not considered standard of care at this point. 
Furthermore, it is unclear whether this type of wound dressing is as beneficial as existing and available 
medically appropriate alternatives including other wound dressings, placental dressings, bovine dressings, 
etcetera. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Kerecis omega3 skin substitute have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Kerecis omega3 skin substitute (Q4158, 15271, 15275).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing, the application of 
fluoride, and oral hygiene instructions (D1330, D1206, D4341) provided on June 1, 2023, to June 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 your benefit for the fluoride application was 
exhausted on June 1, 2023. Coverage for the periodontal scaling and root planing and oral hygiene instructions 
denied correctly as they do not fall within your dental 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, certain limitations apply. The record 
shows your benefit for fluoride application was exhausted on date of service June 1, 2023 (D1206) 
Additionally, coverage for the periodontal scaling and root planing and oral hygiene instructions denied 
correctly as they do not fall within your dental benefits. Therefore, we decided that the Plan does not have to 
pay for periodontal scaling and root planing, the application of fluoride, and oral hygiene instructions (D1330, 
D1206, D4341) provided on June 1, 2023, to June 8, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on March 15, 2022. 
 
You asked the Plan to pay for the medical services. You say that you believe this claim was timely filed. The 
Plan denied your request. The Plan says you did not file this claim 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 medical services was not filed 
until April 14, 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 medical services provided on 
March 15, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transport services provided on January 16, 2022. 
 
You asked the Plan to pay for the ambulance transport services. You say that you did not receive notice of 
these charges from the provider until just recently (2023). You also say that due to the delay of the provider 
filing your claim, you are requesting reconsideration of the charges incurred. The Plan denied your request. The 
Plan says this request is past the allowed 12 month timeframe. 
 
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 ambulance transport services was not filed until February 20, 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 ambulance transport services provided on January 
16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for an endosteal implant, bone graft, extraction, and the 
collection of blood concentrate product (D6104, D7210, D6010, D7921) provided on April 25, 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.  
 
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. 
Therefore, we decided that the Plan does not have to pay more for an endosteal implant, bone graft, extraction, 
and the collection of blood concentrate product (D6104, D7210, D6010, D7921) provided on April 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96374 and 96375 billed for date of service 
April 5, 2023. 
 
You asked the Plan to pay for procedure codes 96374 and 96375. You say that the services were administered 
for anxiety and pain. The Plan denied your request. The Plan says payment for codes 96374 and 96375 are 
bundled into payment for code 64483. 
 
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 96374 and 96375 are column II code to column I code 64483. The 
medical records provided do not show that the services billed with the -59 modifier were distinct procedural 
services. The documentation does not support a different procedure that is not ordinarily performed on the 
same day by the same individual. 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 96374 and 96375 billed for date 
of service April 5, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a leg compression device to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve a compression device. You say that you are requesting reconsideration of 
the denied item. The Plan denied your request. The Plan says the items were not approved. 
 
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 
a leg compression device to be provided by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0676) provided on 
January 9, 2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that the item was medically 
necessary. The Plan denied your request. The Plan says this is not a covered item. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for the pneumatic compression device (E0676) provided on January 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for frames (V2020), single vision sphere lenses (V2100), 
polycarbonate lenses (V2784), scratch resistant coating (V2760), ultra-violet (UV) lenses (V2755), anti-
reflective coating (V2750) and variable asphericity lenses (V2410) provided on March 7, 2023. 
 
You asked the Plan to reimburse for frames (V2020), single vision sphere lenses (V2100), polycarbonate lenses 
(V2784), scratch resistant coating (V2760), ultra-violet (UV) lenses (V2755), anti-reflective coating (V2750) 
and variable asphericity lenses (V2410). You say that you did not expect to pay $349 for one pair of reading 
glasses. The Plan denied your request. The Plan says they pay up to $100.00 per calendar year for eyeglasses. 
The Plan also says that amounts over the $100 allowance are not covered. 
 
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 up to $100 per calendar year for eyeglasses (frames, lens, and lens options) or 
contact lenses. 
 
We looked at the file and the Plan's rules. The Plan rules say that the plan pays up to $100 per calendar year for 
eyeglasses (frames, lens, and lens options) or contact lenses. The Plan rules also say that amounts over the $100 
allowance are not covered. The record shows this benefit was exhausted with this date of service. Based on this 
information, we decided that the Plan's rules for coverage of frames (V2020), single vision sphere lenses 
(V2100), polycarbonate lenses (V2784), scratch resistant coating (V2760), ultra-violet (UV) lenses (V2755), 
anti-reflective coating (V2750) and variable asphericity lenses (V2410) have not been met. Therefore, we 
decided that the Plan does not have to reimburse for frames (V2020), single vision sphere lenses (V2100), 
polycarbonate lenses (V2784), scratch resistant coating (V2760), ultra-violet (UV) lenses (V2755), anti-
reflective coating (V2750) and variable asphericity lenses (V2410) provided on March 7, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services (G0299, G0300, Q5001) provided 
from January 2, 2023, to January 16, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that the services should be covered as 
you disagree with the denial. The Plan denied your request. The Plan says the claim has not been billed with 
the correct admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services (G0299, G0300, Q5001) provided from 
January 2, 2023, to January 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an endosteal implant (D6010) provided on May 12, 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 services denied correctly as they do not fall 
within your dental 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 an 
endosteal implant (D6010) provided on May 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wheelchair provided on March 10, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the wheelchair. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says the services were not authorized. 
 
 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 Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
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 the wheelchair provided on March 10, 2023, by an 
out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for dates of service September 
14, 2022, to October 13, 2022. You asked the Plan to pay for the billed services. You say that there is an NOA on file. The Plan denied your 
request. The Plan says the NOA was not received timely.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is March 18, 2022. The NOA was not received by the Plan until January 13, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health care billed for 
dates of service September 14, 2022, to October 13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that a LTACH level of care would allow the 
enrollee the opportunity to achieve their full potential in their recovery. The Plan denied your request. The Plan 
says the enrollee may stay in the hospital where they are receiving their care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving the appropriate care in the current acute care setting being 
provided by the Plan. The documentation does not support that LTACH services are 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L1 kyphoplasty (22514). 
 
You asked the Plan to pre-approve L1 kyphoplasty. You say that this is medically necessary. The Plan denied 
your request. The Plan says the medical record documents that this enrollee does not meet evidence-based 
criteria. 
 
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 L1 kyphoplasty. Our reviewer says that 
the enrollee does not meet criteria for coverage. Our physician reviewer found detailed documentation is not 
evident regarding diagnostic imaging corroboration of an acute/subacute vertebral compression fracture. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L1 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve L1 kyphoplasty (22514).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block (64624). 
 
You asked the Plan to pre-approve a genicular nerve block. 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 genicular nerve block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found genicular nerve blocks and genicular nerve radiofrequency ablation are considered 
investigational and not medically necessary for the treatment of chronic knee pain, including, but not limited to 
any of the following: degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee 
replacement; as a treatment following knee replacement; or as a treatment for individuals who are not 
candidates for knee replacement surgery. 
 
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 genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block (64624).