Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for radiology services (A9585, 70553, 70544) 
provided August 28, 2020. 
 
You asked the Plan to waive the copayment for the radiology services. You say that you are being double 
billed. 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 $180 
copayment for Advanced Imaging Services.  
 
You have been asked to pay a $180 copayment for the radiology services. The radiology services fall within the 
Advanced Imaging 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 radiology 
services (A9585, 70553, 70544) provided August 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar discography injection for the enrollee. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no documentation of participation in three or more cognitive behavioral therapy 
sessions, and no documentation of the absence of untreated, underlying mental health conditions as a major 
contributor to chronic pain. 
 
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 injection. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this procedure is experimental. More research is needed to show safety and efficacy. There is no spinal 
instability. Hardware is not needed. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve lumbar discography injection for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an innerspring mattress. 
 
You asked the Plan to pre-approve the mattress. You say that this is medically necessary. The Plan denied your 
request. The Plan says this mattress cannot be billed alone. 
 
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 mattress. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is no evidence that you own a hospital bed. There is also no objective physical exam indicating a 
medical need for this mattress. 
 
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 mattress have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an innerspring mattress.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core build up (D2950). 
 
You asked the Plan to pre-approve core build up. You say that the service is medically necessary. 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. Specifically, the service is not listed in the Plan?s benefit chart. This 
means the service is not a covered benefit. Therefore, we decided that the Plan does not have to pre-approve 
core build up (D2950).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intermittent limb compression device and sleeves. 
 
You asked the Plan to pay for intermittent limb compression device and sleeves. You say that these services 
were medically necessary. The Plan denied your request. The Plan says pneumatic compression devices are 
only covered for the treatment of lymphedema or for the treatment of chronic venous insufficiency with venous 
stasis ulcers. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous 
stasis ulcers. Therefore, we decided that the Plan does not have to pay for intermittent limb compression device 
and sleeves.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ConfirmMDx testing rendered on July 24, 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 the services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that ConfirmMDx is covered when specific criteria 
are met. 
 
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 these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the submitted records do not support that 
the enrollee was being considered for a repeat biopsy due to persistent or elevated cancer risk factors. The 
criteria for coverage are therefore not met and the testing was 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 pay for the ConfirmMDx testing rendered on July 24, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve blinatumomab (Blincyto). 
 
You asked the Plan to pre-approve Blincyto. You say that continuation of sequential POMP plus Blincyto is the 
best treatment to keep the enrollee in remission. The Plan denied your request. The Plan says the drug is not 
indicated for use as requested, or in combination with other chemotherapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Blincyto. Our physician reviewer found 
that Blincyto is approved for consolidation as a single agent, but not with other therapy. The documentation 
does not support that the requested drug is safe and effective, and otherwise reasonable and necessary for this 
enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Blincyto have not been met. Therefore, we decided that the Plan does not have 
to pre-approve blinatumomab (Blincyto).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided, by an out-
of-network provider. 
 
You asked the Plan to pay for the medical services. You say that the services were necessary. The Plan denied 
your request. The Plan says the provider is not in-network with the Plan and the services were not urgent or 
emergent. 
 
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 the medical services provided, 
by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain/ceramic dental crown. 
 
You asked the Plan to pre-approve a porcelain/ceramic dental crown. 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 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 a 
porcelain/ceramic dental crown.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for endovascular revascularization services (CPT 37220 and 
CPT 37232) provided to the enrollee on August 2, 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. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 37220: 
 
Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal 
angioplasty 
 
CPT 37232: 
 
Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; 
with transluminal angioplasty (List separately in addition to code for primary procedure) 
 
We asked our coding 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 coding reviewer found the 
operative report does not include documentation of a separate revascularization of iliac artery; therefore, CPT 
37220 cannot be verified. No additional vessels outside of the territory are being treated, so CPT 3732 also 
cannot be verified. 
 
We looked at this coder'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 endovascular revascularization services (CPT 37220 and CPT 37232) provided to the enrollee 
on August 2, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory services rendered on August 
31, 2020. 
 
You asked the Plan to waive the copayment for these services. You say that the copayment should be included 
in your annual women's wellness exam. 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 $10 
copayment for Medicare-covered lab services.  
 
Review of the file shows that you received HPV testing on August 31, 2020. These services are covered by 
Medicare once every five years for women aged 30 to 65. The file shows that you were 78 years old at the time 
the services were rendered; therefore, the services are not covered as an annual screening. You have been asked 
to pay a $10 copayment for these services. These services fall within the Medicare-covered lab 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 the laboratory services rendered on August 31, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a tetanus, diphtheria toxoids and acellular pertussis (TDAP) 
vaccine (90715) and administration (90471) provided on September 30, 2020. 
 
You asked the Plan to pay for a TDAP vaccine and administration. You say that this should be covered because 
you have underlying issues. The Plan denied your request. The Plan says this is covered under Medicare Part 
D. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a TDAP vaccine and 
administration. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to a TDAP vaccine 
and administration. Therefore, we decided that the Plan does not have to pay for a tetanus, diphtheria toxoids 
and acellular pertussis (TDAP) vaccine (90715) and administration (90471) provided on September 30, 2020.  
 
Benefits for a TDAP vaccine and administration 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on September 23, 2020. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you went to the dentist 
because a filling fell out and needed to be repaired. The Plan denied your request. The Plan says this service 
exceeds the frequency limitation in your benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, problem focused limited oral 
evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem 
focused limited oral evaluation (D0140) on May 5, 2020, and your problem focused limited oral evaluation 
(D0140) benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the problem 
focused limited oral evaluation (D0140) provided on September 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive oral exam (D0150) and complete series of 
radiographic images (D0120) provided on September 10, 2020. 
 
You asked the Plan to pay for oral exam and radiographic images. You say that the services should be covered. 
The Plan denied your request. The Plan says you have exhausted you benefits for comprehensive oral exams 
and radiographic images are 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. Specifically, intra-oral radiographic images are not a covered service 
and records indicate you have already exhausted the one comprehensive oral exam you are allowed once every 
three years. Therefore, we decided that the Plan does not have to pay for comprehensive oral exam (D0150) 
and complete series of radiographic images (D0120) provided on September 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the nuclear medicine exam provided on 
January 14, 2020. 
 
You asked the Plan to waive the copayments for the nuclear medicine exam. You say that you were unaware 
you would have a coinsurance. The Plan denied your request. The Plan says you have been charged the correct 
cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 
copayment for all other diagnostic and nuclear medicine radiological services.  
 
You have been asked to pay a $225 copayment for the nuclear medicine exam. The nuclear medicine exam 
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 a nuclear medicine exam provided on January 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee does not 
require close supervision by a rehab physician, or a multidisciplinary team approach for rehab. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 IRF care. Our physician reviewer found 
that the enrollee was admitted to the acute hospital for COVID-19 pneumonia. His medical conditions are 
stable. The complexity of his nursing, medical and rehabilitation needs does not require an acute hospital 
inpatient stay with an interdisciplinary approach to rehab care. While the medical record documents a need for 
physical and occupational therapy, it does not document a need for an intensive rehabilitation program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two removals of residual tooth roots, primary closure of a 
sinus perforation, extraction, drugs or medicaments dispensed in the office for home use, and preventive 
procedure provided. 
 
You asked the Plan to pay for the removals of residual tooth roots, primary closure of a sinus perforation, 
extraction, drugs or medicaments, and preventive procedure. You say that you were sent to an oral surgeon by 
your dentist due to the medical treatment you needed. You also say that you were advised by the Health Plan 
that the medical components would be covered. The Plan denied your request. The Plan says these services are 
dental in nature, and are unrelated to the limited clinical indications. The Plan also says that these services are 
not eligible for coverage under the medical benefit. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking 
the Plan to pay 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 pay for the two removals of residual tooth roots, primary 
closure of a sinus perforation, extraction, drugs or medicaments dispensed in the office for home use, and 
preventive procedure provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the clinical crown lengthening (D4249) provided on January 
2, 2020. 
 
You asked the Plan to pay for the clinical crown lengthening. You say that this service was medically 
necessary. The Plan denied your request. The Plan says this service is not covered by Medicare and you did not 
have a supplemental dental benefit with the Plan. 
 
Medicare generally does not cover dental services. The Plan follows the same rule.  
 
The services you are asking the Plan to pay 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 pay for the clinical crown lengthening 
(D4249) provided on January 2, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services provided June 12, 
2020 to August 9, 2020 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you feel these 2 
ambulance transports should not have been billed to you and you request the billed amount of $188.00 each 
transports be rebilled and considered payment to the ambulance service. The Plan denied your request. The 
Plan says you were charged this cost sharing 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 $220 
copayment for each ambulance trip. You had 2 ambulance trip(s). The Plan charged you $376.00 ($188 + 
$188) for these services. Your responsibility of $188 for both trips is less than the $220 copayment because this 
was the maximum allowable charge. 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 ambulance 
services provided June 12, 2020 to August 9, 2020