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

 
We decided that the Plan does not have to pre-approve the MRI, spinal canal and contents, lumbar; without 
contrast material (CPT Code 72148). 
 
You asked the Plan to pre-approve the MRI. You say that the service is necessary. The Plan denied your 
request. The Plan says the service is not necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our physician reviewer found 
the records do not show a clear and full effort with conservative treatments including physical therapy. Nor was 
there objective evidence of a red flag diagnosis on physical examination or history to bypass conservative 
treatment for this individual. Therefore, this request for MRI lumbar spine will be considered not 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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the MRI, spinal canal and contents, lumbar; without contrast material (CPT Code 72148).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea power scooter.You asked the Plan to pre-approvea power scooter. You say that you need this to be able to go outside.The Plan denied your request. The Plan says this is not covered for use outside the home.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-approvea power scooter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit for the evaluation and management 
of an established patient  (99212) provided. 
 
You asked the Plan to pay for the office visit. You say that you are appealing the notice of denial of payment. 
The provider is on the list of in network specialists and you called to see if a referral was needed and was told 
no referral was needed. The Plan denied your request. The Plan says this service is not covered when rendered 
by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the outpatient office visit for the evaluation and management of an established 
patient  (99212) provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on January 15, 2020 and January 16, 2020 by an out of network provider.You asked the Plan to pay forthe medical services. You say that the facility did not obtain authorization but the physician should not be penalized.The Plan denied your request. The Plan says you did not request prior authorization for the out-of-network 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.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. ThePlan did not pre-approve the servicesat issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay forthe medical services provided on January 15, 2020 and January 16, 2020 by an out of network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ajovy for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says that this is not covered under Part B. 
 
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 Ajovy for the enrollee.  
 
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Superion interspinous spacer (Vertiflex device) (CPT Codes: 22869, 22870).You asked the Plan to pre-approvethe Superion interspinous spacer. You say that the services are necessary.The Plan denied your request. The Plan says this service is considered experimental and investigational as it is not identified as widely used and generally accepted for the proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.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 Superion interspinous spacer. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered an experimental/ investigational procedure. While some trials have been favorable, there is a significant frequency of further surgery required. Therefore, the request is deemed not medically reasonable or 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 the Superion interspinous spacer havenot been met.Therefore, we decided that the Plan does not have to pre-approvethe Superion interspinous spacer (Vertiflex device) (CPT Codes: 22869, 22870).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the occlusal orthotic device adjustments (D7881 x 
2) provided from April 10, 2020, to May 12, 2020. 
 
You asked the Plan to reimburse you for the dental services. You say that you have been dealing with a lot of 
stress. You say that you do not understand why this claim was denied as the claim for the MRI was paid. You 
also say that you would appreciated if all or part of this claim would be reimbursed. The Plan denied your 
request. The Plan says the services in this appeal are dental in nature. The Plan also says that this service is not 
covered by Medicare. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to reimburse you for involve the care, treatment, filling, removal or 
replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not 
covered or paid for by Medicare. Therefore, we decided that the Plan does not have to reimburse you for the 
occlusal orthotic device adjustments (D7881 x 2) provided from April 10, 2020, to May 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram coded 93010 provided on June 4, 
2020. 
 
You asked the Plan to pay for the electrocardiogram. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 93010 is electrocardiogram, routine ECG with at least 12 
leads; interpretation and report only. 
 
We find that CPT code 93010 is not supported in the medical record. Specifically, the documentation includes 
the electrocardiogram strip, however, there is no documentation for an interpretation for the rendering provider. 
Without a physician?s interpretation, note, and signature, computer-generated electrocardiogram reports don?t 
meet the requirements for the professional component of an electrocardiogram. Based on this information, we 
decided that Medicare rules for coverage of the electrocardiogram have not been met. Therefore, we decided 
that the Plan does not have to pay for the electrocardiogram coded 93010 provided on June 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature for the enrollee. 
 
You asked the Plan to pre-approve the elevator. You say that this is medically necessary. The Plan denied your 
request. The Plan says although this item is requested, no allowed amount is listed in the quote submitted. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a power seat elevation feature for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a nuclear imaging study of bones and joints 
(78306) performed. 
 
You asked the Plan to waive the copayment for a nuclear imaging of bones and joints. You say that you have to 
pay extra expenses and out-of-pocket fees as you never had to before. The Plan denied your request. The Plan 
says the correct copayment was 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 $325 
copayment for nuclear medicine services at an outpatient hospital.  
 
You have been asked to pay a $325 copayment for a nuclear imaging of bones and joints. A nuclear imaging of 
bones and joints falls within the "Outpatient hospital 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 a nuclear imaging study of bones and joints (78306) performed.  
 
Your complaint about receiving erroneous or ambiguous information from a representative of the Plan is not a 
valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the 
Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair accessory, power seat elevation system, any 
type (CPT Code E2300). 
 
You asked the Plan to pre-approve the item. You say that you are requesting review of denial of services. The 
Plan denied your request. The Plan says this item is not covered under Medicare or the Health Plan. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the item have not been met. The power seat elevation is a feature 
that is not considered to serve a medical purpose by Medicare. Therefore, we decided that the Plan does not 
have to pre-approve wheelchair accessory, power seat elevation system, any type (CPT Code E2300).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910), the initial periapical x-
ray (D0220), and the additional periapical x-ray (D0230) provided on May 26, 2020. 
 
You asked the Plan to pay for the dental services. You say that the services that you received are medically 
necessary to treat your gum disease and to prevent further tooth loss. The Plan denied your request. The Plan 
says periodontal maintenance is not listed as a covered service. The Plan says periapical x-rays are not listed as 
covered service either. 
 
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 periodontal maintenance and 
periapical x-rays are not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pay for the periodontal maintenance (D4910), the initial periapical x-ray (D0220), and the additional 
periapical x-ray (D0230) provided on May 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203) provided on February 27, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit under 
your contractual policy. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99203) provided on February 27, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on November 20, 
2019. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied codes remain 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. 
 
Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the 
specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the 
records reflect of place of service of a doctor's office (POS 11). 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 laboratory services provided to the enrollee on November 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the lateral exostosis removal (D7471). 
 
You asked the Plan to pre-approve the lateral exostosis removal (D7471). You say that you need the procedure 
done for the dentures to fit correctly. The Plan denied your request. The Plan says the service is not a covered 
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. Therefore, we decided that the Plan does not have to pre-approve the 
lateral exostosis removal (D7471).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve OON services. The Plan denied your request. The Plan says there are in-
network providers readily available and accessible. 
 
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 OON services. Therefore, we decided that the Plan does not have to pre-approve 
home health services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a shower head and shower chair purchased 
from a commercial retail store on July 8, and July 9, 2020. 
 
You asked the Plan to provide coverage for these items. The Plan denied your request. The Plan says these 
items were not purchased from a Medicare approved durable medical equipment provider. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who is not eligible to accept Medicare 
payment. This equipment was purchased from a commercial retrial provider that is not Medicare approved. In 
addition, this equipment is not covered by Medicare. Therefore, we decided that the Plan does not have to 
provide coverage for a shower head and shower chair purchased from a commercial retail store on July 8, and 
July 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on June 15, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
physician?s services. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on June 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics (L3020). 
 
You asked the Plan to pre-approve foot orthotics. You say that foot orthotics are medically necessary. The Plan 
denied your request. The Plan says this item is not a covered benefit for your condition. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3020).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that this will help with pain. The Plan denied your 
request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for Ophthalmology services (99204) provided 
May 26, 2020. 
 
You asked the Plan to reduce the copayment for the Ophthalmology visit. You say that the copayment for an 
eye exam ($15) should be applied. The Plan denied your request. The Plan says the exam provided was 
diagnostic in nature and the correct copayment was 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 $40 
copayment for services to diagnose and/or treat a disease or condition of the eye.  
 
You have been asked to pay a $40 copayment for the Ophthalmology visit. The Ophthalmology visit is 
considered a service to diagnose and/or treat a disease or condition of the eye. The exam provided was not an 
annual routine eye exam. 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 reduce the copayment for Ophthalmology services 
(99204) provided May 26, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance trip provided by a participating provider on April 20, 2020.You asked the Plan to waive the copayment for an ambulance trip. You say that you were not aware that you would owe this much. You say that if you would have known you would have had your children take you home. 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 $225 copayment for ambulance services.You have been asked to pay a $225 copayment for an ambulance trip. An ambulance trip falls 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 an ambulance trip provided by a participating provider on April 20, 2020.