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

 
We decided that the Plan does not have to pay for CPT codes 73110 and 73130 provided on November 26, 
2019. 
 
You asked the Plan to pay for CPT codes 73110 and 73130. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says these services were previously paid. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must confirm that Medicare 
coverage criteria have been met.  
 
In this case, there was not sufficient medical records provided confirming that the services were billed 
correctly. The information submitted does not confirm that more than one set of CPT codes 73110 and 73130 
were provided to the enrollee. The Plan paid for one set of records. Therefore, we decided that the Plan does 
not have to pay for CPT codes 73110 and 73130 provided on November 26, 2019.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for CPT code 99285 provided on November 6, 2019. 
 
You asked the Plan to pay for CPT code 99285. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan is denying payment for the claim in dispute stating that 
CPT code 99285 was previously paid in another claim; however, the Plan did not provide any claims showing 
that they paid for CPT code 99285 provided on November 6, 2019. We find that the Plan has not substantiated 
their reasoning for denial of payment. Therefore, we decided that the Plan has to pay for CPT code 99285 
provided on November 6, 2019.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mental health services services provided on April 6, 2020 
to April 20, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for these OON services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services received are not a covered benefit when 
provided by an OON provider. 
 
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 mental health services services provided on 
April 6, 2020 to April 20, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on February 4, 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 claim was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory; however, the file shows that the specimen was obtained in an office setting and should have been 
billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services 
rendered on February 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) 
lateral branches. 
 
You asked the Plan to pre-approve the RFA of the SI nerves. You say that this treatment should be allowed. 
The Plan denied your request. The Plan says the literature does not support this treatment for SI joint 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 RFA of the SI nerves. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the use of radiofrequency ablation for pain management related to sacroiliitis has not 
been shown to provide clear long-term benefit than standard treatment for chronic sacroiliac joint pain.  Based 
upon review of the medical literature, radiofrequency ablation used for sacro-iliac joint pain is considered 
investigational and not medically necessary - whether using traditional, cooled, or pulsed radiofrequency. The 
review has determined that the requested radiofrequency ablation is not medically necessary or reasonable. 
 
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 RFA of the SI nerves have not been met. Therefore, we decided that the 
Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) lateral branches.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa injections. 
 
You asked the Plan to pre-approve the Euflexxa injections. You say that the enrollee requires this treatment for 
knee pain. The Plan denied your request. The Plan says the enrollee's needs can be met with one of the 
preferred agents. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Euflexxa injections. Our reviewer 
says that the requested drug is not considered reasonable and necessary based on step therapy requirements. 
Our physician reviewer found the enrollee is a 75 year old male with pain related to osteoarthritis of the left 
knee, diagnosis confirmed with imaging studies. He has failed conservative treatment, Euflexxa has been 
requested. There is no documentation of a trial of Orthovisc or Monovisc, the preferred drugs. There is also  no 
indication that the plan's required drug(s) would likely be less effective and/or likely have adverse effects for 
the patient. 
 
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 Euflexxa injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Euflexxa injections.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CPT code 0042T provided on October 12, 2019. 
 
You asked the Plan to pay for CPT code 0042T. 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. Medicare rules say that providers must report services correctly.  
 
We looked at the file and Medicare rules. Medicare specifically denies coverage for CPT code 0042T. Based 
on this information, we decided that Medicare rules for coverage of CPT code 0042T have not been met. 
Therefore, we decided that the Plan does not have to pay for CPT code 0042T provided on October 12, 2019.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care provided on November 24, 
2019. 
 
You asked the Plan to pay for the subsequent hospital care. You say that the enrollee was not enrolled in 
hospice on this date of service. The Plan denied your request. The Plan says Original Medicare would be 
responsible for payment of all Medicare covered services related or unrelated to the enrollees terminal 
condition. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on November 21, 2019. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the subsequent 
hospital care provided on November 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve motorized wheelchair. 
 
You asked the Plan to pre-approve the motorized wheelchair. You say that the motorized wheelchair is 
medically necessary. The Plan denied your request. The Plan says the motorized wheelchair is not medically 
necessary. 
 
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 motorized wheelchair have not been met. You requested an 
indoor/outdoor wheelchair, but the enrollee is not noted to require a wheelchair to accomplish activities of daily 
living in their home or that they lack the strength to propel a manual wheelchair. Additionally, there is no order 
from the physician for this device. Therefore, we decided that the Plan does not have to pre-approve motorized 
wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic casts, core buildup, including any pins when 
required, periodontal maintenance, and resin-based composite provided from February 6, 2020 to March 3, 
2020. 
 
You asked the Plan to pay for the diagnostic casts, core buildup, periodontal maintenance, and resin-based 
composite. You say that you were not informed that the Plan had an annual maximum of 
$1,000, or that you would pay more by going to an out-of-network dentist. You also say that you were advised 
that the Plan would pay 50%. The Plan denied your request. The Plan says the annual maximum coverage for 
dental services is $1,000. The Plan also says that any charges over this amount are your responsibility. 
 
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 $1,000 annual dental 
benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are 
responsible for the full charges of any additional dental services. The record shows that you met the annual 
maximum benefit while processing the claim from the March 3, 2020 date of service, and your annual 
maximum benefit has been exhausted. The Plan is not contractually obligated to pay any more towards this 
claim. Therefore, we decided that the Plan does not have to pay for the diagnostic casts, core buildup, including 
any pins when required, periodontal maintenance, and resin-based composite provided from February 6, 2020 
to March 3, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for chemotherapy drugs and administration 
provided from March 24, 2020 to March 28, 2020. 
 
You asked the Plan to waive the copayment for chemotherapy drugs and administration. You say that you 
disagree with the charges. The Plan denied your request. The Plan says the copayment you are being charged is 
correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for each Medicare-covered chemotherapy drug and the administration of that drug.  
 
The total allowed amount of the claims are $2,978.52, resulting in a coinsurance obligation of $595.70 for 
chemotherapy drugs and administration ($2,978.52 x 20% = $595.70). Chemotherapy drugs and administration 
fall within the Medicare Part B Prescription Drugs benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for chemotherapy drugs and administration provided from March 24, 2020 to March 28, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve twenty (20) speech therapy visits. 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the requested 20 more sessions of ST therapy is not generally 
accepted as specific and effective therapy for your condition. You have had extensive prior therapy. The 
documentation does not indicate specific goals met for you or significant objective functional improvement 
from prior therapy. The documentation does not support that you require the unique skills of a professional 
therapist to safely and effectively provide treatment. Services do not need to safely and effectively be 
performed only by a therapist, or under the supervision of a therapist. You have had extensive therapy and 
there has been caregiver training. The requested services are not  part of a maintenance program and the 
specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or 
deliver a program to maintain your current condition or to prevent or slow further deterioration. 
 
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 twenty (20) speech therapy visits.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a CT scan of the thorax. 
 
You asked the Plan to pre-approve a CT scan of the thorax. You say that the requested CT scan of the thorax is 
medically necessary. The Plan denied your request. The Plan says that the requested CT scan of the thorax is 
not medically necessary. 
 
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 thorax. Our reviewer 
says that the requested CT scan of the thorax is medically necessary. Our physician reviewer found coverage 
criteria are met for a follow-up CT scan of the chest.  This enrollee is a past smoker.  A single 5 mm lung 
nodule was identified on a chest CT from June 2018.  A follow-up in June 2019 showed multiple nodules up to 
5 mm.  A 1-year follow-up was recommended.  That 1-year follow-up was due June 2020.  Therefore the 
follow-up chest CT scan is reasonable and medically necessary; it meets current Fleischner Society guidelines. 
 
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 thorax have been met. Therefore, we decided that the Plan has 
to pre-approve a CT scan of the thorax.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-covered chiropractic services (97012 and G0283) 
provided from January 22, 2020 to April 29, 2020. 
 
You asked the Plan to pay for the non-covered chiropractic services (97012 and G0283). 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 the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the non-covered chiropractic services (97012 and G0283) provided from 
January 22, 2020 to April 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6533. 
 
You asked the Plan to pre-approve the compression stockings. You say that you require the stockings. The Plan 
denied your request. The Plan says these are not a covered service by Medicare. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6533.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the crown (D2750) for tooth #9. We decided that the Plan does not 
have to pre-approve the crown for tooth #30.  
 
You asked the Plan to pre-approve the crowns (D2750). The Plan says the criteria for coverage has not been 
met. 
 
  
We decided that the Plan has to pre-approve the crown (D2750) for tooth #9.  
 
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 for the crown. Our reviewer says that the criteria for 
coverage has been met. Our physician reviewer found that tooth #9 appears to have large mesial and distal 
restorations with recurrent caries. Our reviewer says that a crown restoration is reasonable and necessary to 
provide adequate strength and function. 
 
We also decided that the Plan does not have to pre-approve the crown for tooth #30. 
 
Our reviewer says that the criteria for coverage has not been met. Our physician reviewer found that tooth #30 
appears to have a restoration that does not exhibit defects or recurrent carries and is functional. Our reviewer 
says that the documentation provided does not support the need for a crown restoration for tooth #30. 
Therefore, we decided that the Plan does not have to pre-approve the crown for tooth #30. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eyeglasses with tinted/transitional lenses. 
 
You asked the Plan to pre-approve the tinted/transitional eyeglasses. You say that you were told by your 
neurologist that these glasses could help to reduce some of the causes of your migraines which could be helpful 
and even reduce prescription medication use. The Plan denied your request. The Plan says you do not have 
supplemental routine vision coverage for eyeglasses. Medicare only covers eyeglasses when provided after 
cataract surgery. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
Although the requested item may be appropriate, Medicare does not cover this item and your plan offers no 
supplemental benefit for non-Medicare covered eyewear. Therefore, we decided that the Plan does not have to 
pre-approve eyeglasses with tinted/transitional lenses.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve reduction mammaplasty (CPT Code 19318). 
 
You asked the Plan to pre-approve the services. You say that patients with breast hypertrophy suffer from 
severe symptoms directly related to the weight of their excess breast volume. The Plan denied your request. 
The Plan says that the Medicare rules have not been 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 pre-approve the services. Our physician reviewer 
found the procedure satisfies Medicare medically necessary criteria, as the patient has significantly enlarged 
breasts and the patient's pain has failed conservative analgesia. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve reduction mammaplasty (CPT Code 19318).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bath tub wall rails. 
 
You asked the Plan to pre-approve bath tub wall rails. You say that the bath tub wall rails are medically 
necessary. The Plan denied your request. The Plan says grab bars are not medical in nature and are considered a 
self-help device. 
 
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 bath tub wall rails.