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 MRI is necessary. The Plan denied your request. 
The Plan says the MRI 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 
there is no specific clinical rationale for the requested MRI. There is no documentation of lumbar pain. The 
MRI may be used to evaluate uncomplicated disc disease or herniated nucleus pulposus only when a surgical 
intervention or aggressive treatment is under consideration. This was not documented You did do conservative 
treatment (PT, use of Celebrex, use of a cane) but this was not supported by the documentation that you were 
using these for lumbar pain. A face-to-face clinical evaluation should be performed that includes relevant 
history and physical examination. This was done through telemedicine, which is considered acceptable, 
however, there was no documentation of non-advanced imaging, motor testing or reference to any bowel or 
bladder abnormalities. The lumbar MRI does not meet the reasonable and necessary criteria. The review has 
determined that the requested MRI is not medically reasonable or necessary based on the Medicare rules. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental implants (A9270). 
 
You asked the Plan to pre-approve dental implants. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says that dental implants are not a covered benefit under 
your contractual policy. 
 
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 are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve dental 
implants (A9270).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Superion spacer. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has back pain. The 
Superion spacer is considered experimental in nature, as more research is needed to show safety and efficacy. 
The services are therefore not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Superion spacer.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on April 2, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says due to the enrollee's hospice election at the time of service, this claim should be 
submitted to Original Medicare. 
 
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 
physician services provided to the enrollee on April 2, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on November 25, 2019. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
laboratory services provided on November 25, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram provided on October 11, 2019. 
 
You asked the Plan to pay for the services provided. You say that the services were separate. The Plan denied 
your request. The Plan says only 1 unit of service is allowed per day. 
 
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 code 93010 is not supported in the medical record. The 
records provided do not show that a questionable finding indicated a need for additional testing. 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 electrocardiogram provided on October 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for core build up (D2950) for tooth # 2 provided on July 6, 2020. 
 
You asked the Plan to pay for the dental service. You say that you needed to have this tooth repaired. You say 
that you have opted to have this service instead of a crown as the repair was adequate. You say that if this were 
a filling, this would be covered. You also say that you would prefer not to have a crown. The Plan denied your 
request. The Plan says core build up is covered once per tooth in a 5-year period. The Plan also says that the 
frequency limit has been exceeded. 
 
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 one core build 
up per tooth in a 5-year period has been exceeded. The record shows that the Plan paid for core build up for 
tooth # 2 that you received on April 3, 2018. Therefore, we decided that the Plan does not have to pay for core 
build up (D2950) for tooth # 2 provided on July 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for telehealth services received on July 8, 
2020. 
 
You asked the Plan to waive the copayment for the services. You say that the provider cannot charge for 
telephone calls. The Plan denied your request. The Plan says the copayment was 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 $50 
copayment for telehealth services.  
 
You have been asked to pay a $50 copayment for the services. The services fall within the telehealth 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 telehealth services received on 
July 8, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient skilled nursing facility (SNF) care rendered by 
the out of network (OON) provider from May 6, 2020, through May 31, 2020. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without 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 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. The Plan did not pre-approve the services at 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 for the inpatient skilled nursing facility (SNF) care rendered by the out of network (OON) 
provider from May 6, 2020, through May 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve progressive/no line bifocal lenses (V2781). 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan?s 
denial. The Plan denied your request. The Plan says that these items are not a covered benefit under the 
member?s contractual policy.  
 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case.   
 
We looked at the file and the Plan's rules.  Based on this information, we decided that the Plan's rules for 
coverage of the routine vision and eyewear benefit have not been met. Specifically, bifocal/trifocal lenses 
without lines and progressive bifocals/trifocals are not a covered benefit under the member?s contractual 
policy. Therefore, we decided that the Plan does not have to pre-approve progressive/no line bifocal lenses 
(V2781).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy home services. 
 
You asked the Plan to pre-approve the services. You say that you are having a hard time walking and would 
like to continue the services so they can get you walking again. The Plan denied your request. The Plan says 
you no longer require the skilled needs of a physical therapist based on your functionality progress and ability 
to perform a home exercise program. The Plan states it is no longer a taxing effort for you to leave the home, so 
you are no longer considered home bound. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 services. Our physician reviewer 
found in this case, the documentation doesn't support that you require skilled nursing services or skilled rehab 
services to provide treatment that is medically necessary. You do not require skilled nursing or rehab services 
to effectively provide treatment, care, and/or services in order to improve your condition, perform a 
maintenance program to maintain your condition and/or prevent deterioration. You have been medically stable 
without any recent exacerbations of chronic medical problems or hospitalizations. You have received skilled 
therapy and your functional status has improved. You are no longer home bound and does not required skilled 
in home physical therapy. 
 
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 pre-approve physical therapy home services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an MRI scan of the cervical spine (72141) 
performed on June 8, 2020. 
 
You asked the Plan to waive the copayment for an MRI scan of the cervical spine. You say that it seems that 
you were charged twice. 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 $75 
copayment for each Medicare-covered diagnostic radiology service.  
 
The case record shows that you received an MRI scan of the cervical spine and an MRI scan of the lumbar 
spine on June 8, 2020. You paid for an MRI scan of the lumbar spine on the date of service. You have now 
been asked to pay a $75 copayment for an MRI scan of the cervical spine. An MRI scan of the cervical spine 
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 an MRI scan of the cervical spine (72141) performed on 
June 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge services rendered on February 14, 
2020. 
 
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 code 99239 is 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 99239 is hospital discharge day management; more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, there is no documentation of 
31 minutes or more of discharge services spent on the enrollee. 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 hospital discharge services rendered on February 14, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that the requested drug, Prolia, is medically necessary. The 
Plan denied your request. The Plan says that there was no documentation provided showing previous 
treatments, intolerance or treatment failure. The Plan also says the requested drug is not medically necessary. 
 
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 Prolia. Our reviewer says that the 
requested Prolia injection is medically necessary. Our physician reviewer found the provided documentation 
supports that the enrollee has been actively receiving Prolia, with a positive response. Therefore, the reviewer 
found that Prolia is medically reasonable and 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 Prolia have been met. Therefore, we decided that the Plan has to pre-approve 
Prolia.  
 
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
March 25, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 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 out of network physician 
services provided to the enrollee on March 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete mandibular denture (D5120) provided on July 
10, 2020. 
 
You asked the Plan to pay for the complete mandibular denture. You say that the Plan approved the coverage 
of both the enrollee's complete upper denture and complete lower denture. The Plan denied your request. The 
Plan says the enrollee has exceeded the limits set in the subscriber agreement. 
 
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 Plan offers a $5,000 annual dental 
benefit maximum. The contract says that after the annual maximum benefit maximum has been met, the 
enrollee is responsible for the full charges of any additional dental services. The record shows that the enrollee 
met the annual maximum benefit on July 10, 2020, and the enrollee's annual maximum benefit has been 
exhausted. Therefore, we decided that the Plan does not have to pay for the complete mandibular denture 
(D5120) provided on July 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the nebulizer, with compressor (E0570) and sales tax 
(S9999) purchased on June 18, 2020 from an out of network and non-Medicare certified provider. 
 
You asked the Plan to pay for the nebulizer and sales tax. You say that your old nebulizer quit working. You 
purchased the machine using the safer from home process by ordering online. The Plan denied your request. 
The Plan says if you go to a provider who is not eligible to participate in Medicare, you will be responsible for 
the full cost of the services you receive 
 
The Plan must follow Medicare rules. Medicare rules say that this PPO plan will generally cover your medical 
care as long as the care you receive is considered medically necessary and you receive your care from a 
provider who is eligible to provide services under Original Medicare. As a member of the PPO plan you can 
receive your care from either a network provider or an out-of-network provider. The requested provider in this 
case is not a certified Medicare provider. We found no exception that would require the Plan to pay for these 
items/services. Therefore, we decided that the Plan does not have to pay for the nebulizer, with compressor 
(E0570) and sales tax (S9999) purchased on June 18, 2020 from an out of network and non-Medicare certified 
provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Prednisone and Mycophenolate provided on July 2, 2020, 
and July 3, 2020. 
 
You asked the Plan to pay for the Prednisone and Mycophenolate. You say that the enrollee has never had to 
pay for his medications while in the hospital. The Plan denied your request. The Plan says these drugs are 
considered self-administered, as the enrollee was taking them prior to his emergency room visit. The Plan also 
says that self-administered medications are those that are normally taken by the enrollee without assistance, 
such as oral/topical prescriptions and over the counter medications, and they are not covered by the 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 pay for the Prednisone and 
Mycophenolate provided on July 2, 2020, and July 3, 2020.  
 
Benefits for the Prednisone and Mycophenolate 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on January 13, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must 
receive care from in-network providers with the exception of emergency or urgent care or if the care cannot be 
provided with an in-network provider, which requires prior authorization from the plan 
 
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 January 13, 2020.