Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a surgical extraction (D7210) of tooth # 31.
You asked the Plan to pre-approve the dental service. You say that you did not realized that the extraction would not be covered. The Plan denied your request. The Plan says that surgical extractions are 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. The Plan covers the dental service when the services are medically necessary and reasonable. 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 dental service. Our reviewer says that the surgical extraction is medically necessary. Our physician reviewer found the supplied documentation indicated that the requested code D7210 is a covered service under all fee schedules. The reviewer found that given the Plan documents showing coverage for the procedure, the request would be allowable under the Plan. The reviewer also found there is extensive damage to the buccal structure of tooth # 31. Therefore, the reviewer found that the need for the surgical procedure is medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental service have been met. Therefore, we decided that the Plan has to pre-approve a surgical extraction (D7210) of tooth # 31.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cataract surgery to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve cataract surgery. You say that you would like these services to be provided 
out-of-network. The Plan denied your request. The Plan says these services can be provided in-network. 
 
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 
cataract surgery to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for a revascularization procedure (37224) provided June 12, 2020. 
 
You asked the Plan to pay for the revascularization procedure. You say that the services were medically 
necessary. The Plan denied your request. The Plan says that the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code 37224 is Revascularization, endovascular, open or percutaneous, femoral/popliteal artery(s), unilateral; 
with transluminal angioplasty. 
 
We find that CPT code 37224 is supported in the medical record. Specifically, review has determined that the 
operative report documents the procedure billed. Based on this information, we decided that Medicare rules for 
coverage of the revascularization procedure have been met. Therefore, we decided that the Plan has to pay for a 
revascularization procedure (37224) provided June 12, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on October 18, 2019. 
 
You asked the Plan to pay for the services provided. You say that the procedure was done on both sides. The 
Plan denied your request. The Plan says the billed services 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. 
 
We looked at the file and the rules. We find that CPT codes are not supported in the medical record. The 
documentation does not show that neither bilateral services, nor the dosage of the drugs were provided on the 
date of service at issue. The documentation does include an amendment. However, the amendment does not 
indicate the date of service it is pertaining to. 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 medical services 
provided on October 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pain management services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve pain management services. You say that you would like approval to see this 
recommended provider. The Plan denied your request. The Plan says there are in-network providers available 
for these 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 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 
pain management 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 pay for the parenteral nutrition solution (B4185) and home infusion 
therapy (S9365) provided from January 10, 2020 to January 16, 2020. 
 
You asked the Plan to pay for the parenteral nutrition solution (B4185) and home infusion therapy (S9365). 
You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The 
Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating 
physician before dispensing any DMEPOS item to a beneficiary. Medicare rules also say that providers must 
report services correctly. Providers must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. There is no valid physician order for the parenteral nutrition supplies 
(B4185). Furthermore, CPT code S9365 has a status code of "I" under the Medicare Physicians Fee Schedule 
Database (MPFSDB) and is not valid for Medicare purposes. Medicare uses another code for reporting of, and 
payment for, this service. Therefore, we decided that the Plan does not have to pay for the parenteral nutrition 
solution (B4185) and home infusion therapy (S9365) provided from January 10, 2020 to January 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the charges for the two emergency room (ER) visits provided 
on February 12, 2020 and February 15, 2020. 
 
You asked the Plan to waive the charges for the ER visits. You say that the Plan paid these claims months after 
you received the services and now you are being billed. You do not believe you should owe anything for these 
visits. The Plan denied your request. The Plan says your contract indicates that there is a $90 emergency room 
copayment per visit. These copayments were correctly 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 $90 
copayment for emergency room services.  
 
You have been asked to pay a $90 copayment for each of the ER visits. The ER visits fall within the emergency 
room 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 charges for the two emergency room (ER) 
visits provided on February 12, 2020 and February 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the debridement services rendered on May 30, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure codes 11044 and 11043 are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 11044 is debridement, bone (includes epidermis, dermis, 
subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq cm or less. The definition of code 11043 is 
debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); first 20 
sq cm or less. 
 
We find that CPT codes 11044 and 11043 are not supported in the medical record. Specifically, there is no 
documentation of bone debridement of the first 20 sq cm to support code 11044. Code 11043 is a column II 
code when billed with column I code 11043 and not separately payable. Based on this information, we decided 
that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does 
not have to pay for the debridement services rendered on May 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mattress with a massage feature. 
 
You asked the Plan to pre-approve a mattress with a massage feature. You say that this is medically necessary. 
The Plan denied your request. The Plan says this is 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 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 mattress with a massage feature.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ER visit provided on July 16, 2020. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you were in the waiting room for two 
hours before you left. 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 $90 
copayment per emergency room visit within or outside the service area. 
 
You have been asked to pay a $90 copayment for the ER visit. The ER visit falls within the "Emergency care" 
benefit category. The records show that you had an electrocardiogram, laboratory tests and infusions in the ER. 
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 ER visit provided on July 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom fitted ankle foot orthoses (L2330, L1940, 
L2820) for the enrollee. 
 
You asked the Plan to pre-approve custom fitted ankle foot orthoses. You say the requested orthoses are 
medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. The 
Plan states that Medicare covers a custom brace for enrollees who require stabilization for medical reasons and 
have the potential to benefit functionally. The records show this enrollee complained of toenail fungal infection 
and difficulty wearing shoes due to pain. The physical examination of the enrollee shows signs of vascular 
disease and peripheral neuropathy (diminished sensation to sharp dull and vibratory sense) but there was no 
manual muscle testing performed to document weakness. Medicare coverage criteria are not met.  
 
The Plan must follow Medicare rules. Medicare has specific coverage criteria for custom orthoses. The 
statements made by the provider are not substantiated by the medical records provided. The enrollee does not 
currently use a mobility assist device. The records state a need for stabilization, but no current unstable 
movement is reported by means of actual diagnostics. There has been no trial and failure of a prefabricated 
orthosis. The records lack results of testing and/or diagnostics to determine muscle function. Medicare 
coverage criteria are not met.  Therefore, we decided that the Plan does not have to pre-approve custom fitted 
ankle foot orthoses (L2330, L1940, L2820) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing and localized 
delivery of antimicrobial agents to be rendered by an OON provider. 
 
You asked the Plan to pre-approve the periodontal scaling and root planing and localized delivery of 
antimicrobial agents. You say that this provider is familiar with you, and you do not want to go to another 
provider. The Plan denied your request. The Plan says you have requested to be seen by an OON provider. The 
Plan also says that dental services are only covered by your Health Plan for in-network dentists. 
 
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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pre-approve 
periodontal scaling and root planing and localized delivery of antimicrobial agents to be rendered by an OON 
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diabetic supplies provided on January 15, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for diabetic supplies. You say that you would like this appeal reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 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 diabetic supplies provided on January 15, 2020 by 
an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transcutaneous electrical nerve stimulation (TENS) 
device. 
 
 
 
You asked the Plan to pre-approve a TENS device. You say that you need a TENS device for pain relief. The 
Plan denied your request. The Plan says you are not enrolled in an approved clinical study. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a TENS device. have not been met. Therefore, we decided that the Plan does not have to pre-
approve a transcutaneous electrical nerve stimulation (TENS) device.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest (71250) 
and a CT scan of the abdomen (74160). 
 
You asked the Plan to pre-approve a CT scan of the chest and a CT scan of the abdomen. You say that the 
services are necessary. The Plan denied your request. The Plan says based on the documentation provided, 
coverage criteria has not been met. 
 
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 a CT scan of the chest and a CT scan of 
the abdomen. Our reviewer says that the services are not medically necessary. Our physician reviewer found 
review of NCCN guidelines for B cell lymphoma reveals imaging in the form of CT of the chest, abdomen and 
pelvis is recommended to not exceed annually after 2 years of completion of chemotherapy absent clinical 
signs of recurrence. This enrollee's last CT of the chest, abdomen and pelvis was May 5, 2020 and was 
negative. 
 
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 CT scan of the chest and a CT scan of the abdomen have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the 
chest (71250) and a CT scan of the abdomen (74160).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower 
denture (D5120). 
 
You asked the Plan to pre-approve the dental items. You say that the enrollee is having trouble biting when she 
eats. You say that the enrollee's current dentures are extremely worn and occlusion is poor. You also say that 
new dentures are recommended to restore function. The Plan denied your request. The Plan says dentures are 
covered once every 5 plan years. The Plan also 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, the frequency limit of once every 5 
plan years has been reached. The record shows that the Plan paid for dentures that the enrollee received on June 
22, 2017. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110) 
and a complete lower denture (D5120).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda (J9271). 
 
You asked the Plan to pre-approve Keytruda. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Keytruda. Our reviewer says that the 
medication is medically necessary. Our physician reviewer found review of compendia notes Keytruda is 
approved for individuals with PDL-1 expression. This was not supported in reviewed documentation. Without 
this, medical necessity cannot be determined. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda (J9271).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2752) for tooth # 5. 
 
You asked the Plan to pre-approve the dental service. You say that you have been in pain, especially in the 
cold, with something hot or when it is windy. You say that you have had a lot of fillings in your front tooth. 
The Plan denied your request. The Plan says crowns are not a covered service. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the services you received are dental in 
nature. The Plan?s dental coverage falls under Medicaid?s jurisdiction. The services you are asking the Plan to 
pre-approve 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 pre-approve a crown (D2752) for tooth # 5.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the device is necessary to prevent 
deep vein thrombosis. The Plan denied your request. The Plan says the pneumatic compression device is not 
covered by Medicare to prevent deep vein thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism is a preventive service. PCDs billed by E0675 are not 
covered. 
 
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. 
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided 
that the Plan does not have to pay for a pneumatic compression device.