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

We decided that the Plan does not have to pay for radiology services (CPT 71045) provided to the enrollee on 
July 29, 2020. 
 
You asked the Plan to pay for the services. You say that the enrollee had multiple exams on the date of service. 
The Plan denied your request. The Plan says the billing representative verified that the claim was submitted to 
the plan twice. 
 
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 71045 is radiologic examination, chest. 
 
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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found there are 
2 separate dictations in the file. On one dictation the radiologist. compares the exam to a prior study of 7/25/20 
and signed off on the study at 20:04 on 7/29/20.  Importantly, there is no clinical indication listed in the report 
by the radiologist. A second report also dated 7/29/20 at 3:05 AM was dictated by another doctor, and 
compared to a prior exam of 7/27/20 and then signed off at 7:34 AM on 7/29/20. Importantly, this doctor listed 
an indication for the exam as "shortness of breath" which is an appropriate symptom as an indication. As it 
cannot be determined with certainty that there are 2 separate examinations is that the chest x-ray would not 
qualify for reimbursement anyway, absent a dictated indication for the exam. Thus, one reimbursement for 
what appears to be the same exam billed twice by two separate radiologists should be honored. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for radiology services (CPT 71045) provided to the enrollee on July 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-network provider. 
 
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says that 
enrollees are entitled to receive services from out-of-network providers for emergency or out-of-area urgently 
needed services. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by the out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cone beam CT with interpretation (D0367). 
 
You asked the Plan to pre-approve the dental service. You say that you have cuts on your mouth that came 
from an infection. You say that you need implants. You also say that these services need to be approved so that 
you can have the work done. The Plan denied your request. The Plan says cone beam CT with interpretation is 
not listed as 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 pre-approve a 
cone beam CT with interpretation (D0367).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for an iStent (0191T) provided on June 11, 2020. 
 
You asked the Plan to pay for an iStent. You say that this is a covered service. The Plan denied your request. 
The Plan says that the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that one iStent is considered medically reasonable and 
necessary for the treatment of adults with mild or moderate open-angle glaucoma and a cataract when the 
individual is currently being treated with an ocular hypotensive medication and the procedure is being 
performed in conjunction with cataract surgery. 
 
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 an iStent. Our reviewer says that the criteria 
for coverage of an iStent have been met. Our physician reviewer found it is documented that the enrollee had 
low tension glaucoma, and was being treated with Latanoprost and Dorzolamide. The procedure performed in 
conjunction with cataract surgery and only one stent was inserted. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an iStent have been met. Therefore, we decided that the Plan has to pay for an 
iStent (0191T) provided on June 11, 2020.  
 
 
 
 
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prefabricated post and core in addition to a crown 
(D2954) for teeth # 9 and 10. 
 
You asked the Plan to pre-approve the prefabricated post and core in addition to a crown. You say that the 
services are necessary. The Plan denied your request. The Plan says prefabricated post and core in addition to a 
crown is not listed as 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 pre-approve a 
prefabricated post and core in addition to a crown (D2954) for teeth # 9 and 10.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xiidra 5% eye drops for the enrollee. 
 
You asked the Plan to pre-approve the eye drops. You say that this is medically necessary. The Plan denied 
your request. The Plan says Medicare says Part B programs can only provide limited benefits for prescription 
drugs. 
 
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 Xiidra 5% eye drops for the 
enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repairs to a toilet seat lift. 
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 covered. 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
The services at issue are repairs to a toilet seat lift. The toilet seat lift does not serve a purpose that is primarily 
medical in nature and is not covered by Medicare; therefore, the repairs are also not covered. Therefore, we 
decided that the Plan does not have to pre-approve repairs to a toilet seat lift.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ozempic. 
 
You asked the Plan to pre-approve Ozempic. The Plan denied your request. The Plan says this drug is not 
covered under the enrollee's Part B 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 Ozempic.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the guided tissue regeneration (D4266), the bone 
replacement graft (D4263), and the treatment of complications (post-surgery) (D9930) provided from 
December 17, 2019, to July 31, 2020. 
 
You asked the Plan to pay for the dental services. You say that you were referred by your general dental group 
for the dental procedure. You say that the procedure was much more beneficial to your overall good health. 
You also say that it probably prevented further gum and bone density. The Plan denied your request. The Plan 
says the services you received are not listed as covered services. 
 
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 services you received are not 
among those covered under this benefit. The Evidence of Coverage clearly states that any services not listed are 
not covered. Therefore, we decided that the Plan does not have to pay for the guided tissue regeneration 
(D4266), the bone replacement graft (D4263), and the treatment of complications (post-surgery) (D9930) 
provided from December 17, 2019, to July 31, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from December 11 
to December 12, 2019. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the records provided support the need 
for an inpatient level of care. The Plan denied your request. The Plan says an acute inpatient admission was not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee presented to the emergency room on December 11, 2019, with 
complaints of increased shortness of breath. The evaluation revealed congestive heart failure with no evidence 
of acute coronary syndrome. She was treated with supplemental oxygen and IV Lasix and was admitted to 
telemetry. She underwent an echocardiogram which revealed an ejection fraction of 55%. She was discharged 
home on December 12, 2019. The review has determined that the record  did not show that at the time of 
inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care 
(including earlier ED and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from December 11 to December 12, 
2019.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided to the enrollee from June 21, 
2019, to June 27, 2019. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that these services were medically 
necessary. The Plan denied your request. The Plan says that that they were unable to determine if these services 
were medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. The record 
showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's 
necessary hospital care (including earlier emergency department and/or observation care) would span two 
midnights. Our physician reviewer found that the enrollee's condition met Medicare criteria for the acute 
inpatient hospital care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided to the enrollee from June 21, 2019, to June 27, 2019.  
 
 
 
 
 
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 Coflex placement. 
 
You asked the Plan to pre-approve Coflex placement. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested services are 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 Coflex placement. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation supports that the enrollee has a diagnosis of spinal stenosis of the 
lumbar region. There is no documented spinal instability. The documentation does not support that Coflex 
stabilization is needed. Therefore, the enrollee does not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Coflex placement have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Coflex placement.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete dentures (D5110 and D5120). 
 
You asked the Plan to pre-approve complete dentures. You say that the service is medically necessary. The 
Plan denied your request. The Plan says you have exhausted the maximum frequency for this benefit. 
 
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. Records indicate you received this benefit on August 20, 2020. This 
means you have exhausted the maximum count allowed per period. Therefore, we decided that the Plan does 
not have to pre-approve complete dentures (D5110 and D5120).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection provided by a participating 
provider. 
 
You asked the Plan to waive the coinsurance for an injection. You say that you do not know why you are 
receiving this bill. The Plan denied your request. The Plan says the correct coinsurance 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for an injection. The allowed amount is 
$1,220. The total amount you are being asked to pay is $244 ($1,220 x 20% = $244). An injection falls within 
the Medicare Part B prescription drugs 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 coinsurance 
for an injection provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110). 
 
You asked the Plan to pre-approve the dental item. You say that you need the dentures. You say that you need 
them to eat given that you are losing weight due to cancer. The Plan denied your request. The Plan says 
dentures are covered once per arch every 60 months. The Plan says that the frequency limit has been reached. 
 
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 and the upper denture is listed as 
covered, the frequency limit of once per arch, every 60 months. The record shows that you received a complete 
upper denture on November 9, 2017, thus exhausting the benefit. Therefore, we decided that the Plan does not 
have to pre-approve a complete upper denture (D5110).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture provided to the enrollee from January 8, 2020, 
to March 31, 2020. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says while a portion of this claim was paid, Medicare coverage criteria are not met as the 
services were not ordered by nor supervised by a medical professional recognized by Medicare to provide 
health and medical services. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for 
acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no 
more than 20 sessions per year. Services must be ordered and supervised by an appropriate provider. We 
looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the 
acupuncture services have not been met. Specifically, the services provided were not ordered and/or supervised 
by a Medicare approved provider. Therefore, we decided that the Plan does not have to pay for acupuncture 
provided to the enrollee from January 8, 2020, to March 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a three-wheeled mobility scooter. 
 
You asked the Plan to pre-approve these services. You say that you need the item for grocery shopping. The 
Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a three-wheeled mobility scooter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for medical nutrition therapy (97802) received on January 21, 
2020. 
 
You asked the Plan to pay for medical nutrition therapy. You say that these services were medically necessary 
and appropriate. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules authorize coverage for medical nutrition therapy only for 
enrollees who have diabetes or a renal disease.  
 
We looked at the file and Medicare rules. The case record does not document that the enrollee has diabetes or a 
renal disease. Based on this information, we decided that Medicare rules for coverage of medical nutrition 
therapy have not been met. Therefore, we decided that the Plan does not have to pay for medical nutrition 
therapy (97802) received on January 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a 
participating provider on June 25, 2020. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you thought your 
copayment would only be $35. The Plan denied your request. The Plan says the correct copayment 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 $200 
copayment for outpatient surgery.  
 
You have been asked to pay a $200 copayment for an outpatient surgery. The injection that was provided is 
considered and outpatient surgery; therefore, the correct copayment has been applied. An outpatient surgery 
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 
an outpatient surgery provided by a participating provider on June 25, 2020.