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

 
We decided that the Plan does not have to pre-approve CT scan of thorax, abdomen, and pelvis. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show the proper type of workup. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically 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 pre-approve the scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found a review of the records 
shows a smoking history which is not quantified. The last chest x-ray of 2019 was negative. You have not had 
an endoscopy or colonoscopy. PSA has been normal. Also, as you weigh only 125 pounds an ultrasound of the 
abdomen and pelvis may be of use for occult disease but has not been done. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve CT scan of thorax, abdomen, and pelvis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup (D2950) and endodontic therapy (D3310). 
 
You asked the Plan to pre-approve core buildup and endodontic therapy. You say that the service is medically 
necessary for this enrollee. The Plan denied your request. The Plan says the service is not covered under the 
benefit plan. 
 
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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core 
buildup (D2950) and endodontic therapy (D3310).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional 15 minutes of deep sedation/general 
anesthesia. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is a maximum interval of 30 minutes. 
 
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 requested items or services are not 
among those covered under this benefit. 30 minutes of sedation have already been covered. Any subsequent 
time interval cannot be approved. Therefore, we decided that the Plan does not have to pre-approve additional 
15 minutes of deep sedation/general anesthesia.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept Procedure. 
 
You asked the Plan to pre-approve Intracept Procedure (22899) with the Intracept Intaosseous Nerve Ablation 
System, and Destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging 
guidance (e.g., fluoroscopy), lumbar/sacrum (C9752). You say that this treatment is the most viable treatment 
to achieve relief of the enrollee's chronic low back pain. The Plan denied your request. The Plan says the health 
plan states the intracept procedure is considered experimental and investigational. 
 
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 Intracept Procedure (22899) with the 
Intracept Intaosseous Nerve Ablation System, and Destruction of intraosseous basivertebral nerve, first two 
vertebral bodies, including imaging guidance (e.g., fluoroscopy), lumbar/sacrum (C9752). Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Intracept procedure is experimental. More research is needed to show safety and efficacy. 
 
 
 
 
 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Intracept Procedure (22899) with the Intracept Intaosseous Nerve Ablation 
System, and Destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging 
guidance (e.g., fluoroscopy), lumbar/sacrum (C9752) have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept Procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of an impacted tooth (D7240) provided on 
August 26, 2020. 
 
You asked the Plan to pay for the removal of an impacted tooth. You say that you were advised that you 
needed to make a deposit for the services but that you would get it back. You also say that you believe they 
were being dishonest and are trying to keep your money. The Plan denied your request. The Plan says removal 
of an impacted tooth is not a covered service. 
 
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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
removal of an impacted tooth (D7240) provided on August 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for debridement provided on June 1, 2020. 
 
You asked the Plan to waive the copayment for debridement. You say that you feel that you should only owe a 
$50 copayment not a $300 copayment as this is a follow-up to a surgery. The Plan denied your request. The 
Plan says the claims were processed correctly and you are being charged the correct amount. 
 
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 $300 
copayment for outpatient surgery, including services provided at hospital outpatient facilities. 
 
You received debridement at an outpatient hospital facility on June 1, 2020. Debridement is considered an 
outpatient surgical procedure. Therefore, you are responsible to pay the $300 copayment.   
 
You have been asked to pay a $300 copayment for debridement. Debridement falls within the outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 copayment for debridement provided on June 1, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-ray provided on August 24, 2020. 
 
You asked the Plan to waive the copayment for the x-ray. You say that the radiology department took an x-ray 
of your foot instead of your ankle. You say that you shouldn't be required to pay for the hospital's error. The 
Plan denied your request. The Plan says the copayment applied 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 $45 
copayment for each Medicare-covered x-ray.  
 
You have been asked to pay a $45 copayment for the x-ray. The x-ray falls within the "Outpatient diagnostic 
tests and therapeutic services and supplies" 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 copayment 
for the x-ray provided on August 24, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on June 9, 
2020. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you feel that the charges are 
too high. The Plan denied your request. The Plan says the claims were processed correctly and you are being 
charged the correct amount. 
 
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 $250 
copayment for ambulance services.  
 
You have been asked to pay a $250 copayment for ambulance services. Ambulance services fall within the 
ambulance 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 copayment for ambulance services 
provided on June 9, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the co payment for an x-ray provided by a participating 
provider. 
 
You asked the Plan to waive the co payment for an x-ray. You say that you do not agree with these co payments. 
The Plan denied your request. The Plan says the correct co payment has been applied. 
 
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 outpatient diagnostic tests/x-rays.  
 
You have been asked to pay a $30 copayment for each x-ray. The total amount you are being asked to pay is 
$60 ($30 x 2 x-rays = $60). Evidence was provided to show that wo x-rays were taken; therefore, the correct 
copayment has been applied. an x-ray falls within the outpatient diagnostic tests/x-rays 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 copayment for an x-ray provided by a participating provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on July 3, 2020. 
 
You asked the Plan to pay for the services provided. You say that the test was ordered to help determine the 
best course of treatment for the enrollee's cancer. The Plan denied your request. The Plan says to report a 
comprehensive genomic profile, service providers should use CPT code 81479. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and the rules. We find that the gene panel at issue has not been billed correctly. The rules 
say that if no CPT code accurately describes the procedure performed, the lab may report CPT code 81479 with 
one unit of service. Based on this information, we decided that Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pay for the gene panel testing provided on July 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecomplete maxillary denture and partial mandibular denture.You asked the Plan to pre-approvethe dentures. You say that this is medically necessary.The Plan denied your request. The Plan says the benefit has been exhausted for the 2020 plan year.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. The Plan covers dentures once every five years.The records show that dentures were last received on May 31, 2017. This is less than five years ago. Based on this information, we decided that the Plan's rules for coverage of the dentures have not been met.Therefore, we decided that the Plan does not have to pre-approvecomplete maxillary denture and partial mandibular denture.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for a duplex scan of extremity veins provided on January 17, 2020. 
 
You asked the Plan to pay for the duplex scan of extremity veins. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's 
terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the 
effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers 
attending physician services and all care unrelated to the terminal illness until the first day of the month following the 
month in which hospice was revoked or discharged. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. 
Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill 
Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided 
that the Plan does not have to pay for a duplex scan of extremity veins provided on January 17, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab service provided on October 29, 2019. 
 
You asked the Plan to pay for the lab service. You say that the test that was ordered was performed. The Plan 
denied your request. The Plan says the billed code cannot be verified. 
 
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 87798 is infectious agent detection by nucleic acid (DNA 
or RNA), not otherwise specified; amplified probe technique, each organism. We find that CPT code 87798 is 
not supported in the medical record. The file shows that a molecular urine panel was ordered. The 
documentation does not provide a specific description of the test that is associated with the unspecified code. 
Based on this information, we decided that Medicare rules for coverage of the lab service have not been met. 
Therefore, we decided that the Plan does not have to pay for the lab service provided on October 29, 2019.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nerve conduction studies (95907)  needle electromyography 
procedures (95886) 
 
You asked the Plan to pay for the nerve conduction studies. You say that the records provided should support the 
necessity of the services in dispute. The Plan denied your request. The Plan says the records do not support the service 
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, we find that CPT code 95907 and 95886 is not supported in the medical record. Specifically, the technical 
report did not include documentation of nerve conduction studies.  The technical report did not include documentation of 
a complete needle electromyography, per each extremity with related paraspinal areas when performed, done with nerve 
conduction, amplitude and latency/velocity study; for five or more muscles studied, innervated by three or more nerves or 
four or more spinal levels (listed separately in addition to code for primary procedure). Based on this information, we 
decided that Medicare rules for coverage of the nerve conduction studies have not been met. Therefore, we decided that 
the Plan does not have to pay for the nerve conduction studies (95907)  needle electromyography procedures (95886).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for arthroscopy provided from June 19, 2020, 
to July 8, 2020. 
 
You asked the Plan to waive the copayments for arthroscopy. You say that you feel that you should only owe a 
$20 copayment per each visit. The Plan denied your request. The Plan says the claims were processed 
correctly, and you are being charged the correct amount. 
 
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 $200 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
You received arthroscopy from June 19, 2020, to July 8, 2020, for a total of 8 services. Arthroscopy is 
considered an outpatient surgical procedure. Therefore, you are responsible to pay a $137.93, which is less than 
the $200 copayment per each visit. The total amount you owe is: $137.93 (copayment) x 8 = $1,103.44. 
 
You have been asked to pay the total copayment amount of $1,103.44 for arthroscopy. Arthroscopy falls within 
the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical 
centers 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 copayments for arthroscopy provided from June 
19, 2020, to July 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve a power scooter. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the documentation is missing required information. 
 
The Plan follows Medicare rules. Medicare rules say that Power Mobility Device bases require a Standard 
Written Order (SWO) prior to delivery. 
 
The file shows that there is no written order or prescription for the requested power scooter. This means that 
Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a power scooter.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy provided on 
July 8, 2020. 
 
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that you feel you should 
not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan 
denied your request. The Plan says you received a diagnostic colonoscopy on the date of service at issue in this 
appeal. The Plan says that the correct copayment has applied per your contract with the Plan. 
 
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 $300 
copayment for Outpatient surgery.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you had a diagnostic 
colonoscopy on July 8, 2020, as you had a polyp removed during the procedure. You have been asked to pay a 
$300 copayment for the diagnostic colonoscopy. The diagnostic colonoscopy falls within the Outpatient 
surgery 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 copayment for the diagnostic colonoscopy 
provided on July 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an outpatient surgery provided by a 
participating provider on July 30, 2020. 
 
You asked the Plan to waive the deductible for an outpatient surgery. You say that you do not agree with these 
charges. The Plan denied your request. The Plan says the correct deductible amount has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $500 deductible for outpatient surgery/in-network.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient 
surgery/in-network. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a 
$500 deductible for outpatient surgery/in-network. This cost sharing is a contractual obligation that had not 
been met at the time an outpatient surgery was received on July 30, 2020.  The total amount you are being 
asked to pay is $381.82. Therefore, we decided that the Plan does not have to waive the deductible for an 
outpatient surgery provided by a participating provider on July 30, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic digital breast tomosynthesis 
provided on August 31, 2020. 
 
You asked the Plan to waive the copayment for diagnostic digital breast tomosynthesis. You say that you 
disagree with the charges because this should be considered preventative. The Plan denied your request. The 
Plan says the claims were processed correctly and you are being charged the correct amount. 
 
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 $60 
copayment for X-rays and ultrasounds. 
 
The record shows that you have a personal history of breast cancer. Therefore, the digital breast tomosynthesis 
provided on August 31, 2020, is considered diagnostic and you are responsible to pay the allowed amount of 
$56.91, which is less than the $60 copayment.  
 
You have been asked to pay $56.91 for diagnostic digital breast tomosynthesis. Diagnostic digital breast 
tomosynthesis falls within the outpatient diagnostic tests and therapeutic services and supplies 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 copayment for diagnostic digital breast tomosynthesis provided on August 
31, 2020.