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

 
We decided that the Plan does not have to pre-approve a pontic (D6241) for tooth # 14 and retainer crowns 
(D6751) for teeth # 13 and 15. 
 
You asked the Plan to pre-approve the dental services. You say that you already have a bridge for teeth # 13, 
14, and 15. You say that you need a new one because it is broken already. The Plan denied your request. The 
Plan says only a single maxillary anterior tooth can be considered for replacement with a fixed bridge. The Plan 
also says that the requested bridge is beyond the scope of the policy benefit coverage. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the dental 
services 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 services. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found although the existing bridge has 
failed, it would not have met the criteria for initial placement, and does not meet the criteria presently. The 
reviewer found that there is no documented physical or neurological disability that would preclude the use of a 
removable appliance. The reviewer found that given the lack of support for the very limited circumstances 
which would allow for a fixed appliance, there is no necessity for the requested procedure under the Plan. 
 
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 services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a pontic (D6241) for tooth # 14 and retainer crowns (D6751) for teeth # 13 and 15.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the utilization of personal protective equipment (PPE) and 
decontamination of the ambulance (A0999) provided on April 9, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that effective January 1, 2006, items and services 
which include but are not limited to oxygen, drugs, extra attendants, supplies, electrocardiogram (EKG), and 
night differential are no longer paid separately for ambulance services.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of this service have not been met. Specifically, the service provided is not separately payable from the 
ambulance transport. Therefore, we decided that the Plan does not have to pay for the utilization of personal 
protective equipment (PPE) and decontamination of the ambulance (A0999) provided on April 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for initial hospital care services (CPT 99221) provided to the 
enrollee on April 24, 2020. 
 
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 an initial hospital care code (with modifier AI) was billed by the same provider for date of 
service April 22, 2020. 
 
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 99221 is "initial hospital care, per day, for the evaluation 
and management of a patient." 
 
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 physician reviewer found the 
enrollee was admitted to the hospital on April 23, 2020 and discharged on April 30, 2020. The plan claims 
show that the provider was paid for an initial hospital care service, therefore, any evaluation and management 
codes would be reported as subsequent care, CPT codes 99231-99233. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this should be paid for. have not been met. Therefore, we decided that the Plan 
does not have to pay for initial hospital care services (CPT 99221) provided to the enrollee on April 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea maxillary partial denture (D5213) and a mandibular partial denture (D5214).You asked the Plan to pre-approvethe maxillary and mandibular partial dentures. You say that you do not have the money to pay for your teeth. You also say that you need the dentures so you can eat.The Plan denied your request. The Plan says these services exceed the maximum count allowed per period.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicarecoverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, partial dentures are limited to one procedure every five plan years. The record shows that you received a maxillary partial denture (D5213) and a mandibular partial denture (D5214) on November 12, 2019 and your dentures benefit has been exhausted.Therefore, we decided that the Plan does not have to pre-approvea maxillary partial denture (D5213) and a mandibular partial denture (D5214).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the professional services for allergen immunotherapy 
(95115) provided on July 10, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for allergen immunotherapy. You say that the services rendered were medically 
necessary. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent 
services rendered by an out-of-network 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 professional services for allergen 
immunotherapy (95115) provided on July 10, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested physician's services. 
 
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says you 
are required to use in-network providers for your medical care. The only exceptions are medical emergencies. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the 
requested physician's services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an electrocardiogram (EKG) provided to the enrollee on 
February 11, 2020. 
 
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says an echocardiogram is not covered as part of a pre-operative examination in an absence 
of signs or symptoms. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found only the EKG is provided. Although the enrollee is elderly, there are no preoperative evaluation records 
nor co-morbidity diagnoses to justify the medical reasoning for a preoperative EKG. The cardiac risk of the 
surgical procedure being planned is not documented either. The need for an EKG pre-operatively per 
AHA/ACC guidelines is based on both the assessment of the cardiac risk of the enrollee and the procedure 
being planned. In the absence of information on these or a co-morbid diagnosis justifying the need for a 
preoperative EKG, it does not meet medical necessity criteria. 
 
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 pay for an electrocardiogram (EKG) provided to the enrollee on February 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair for the enrollee. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says the required information was not received. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
There is no evidence of a home evaluation. This would be able to indicate that the enrollee's home is safe for 
use of the requested wheelchair. Based on this information, we decided that Medicare rules for coverage of the 
wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a power 
wheelchair for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to preapprove intermittent limb compression device. 
 
You asked the Plan to preapprove intermittent limb compression device. You say that the enrollee requires the 
device. The Plan denied your request. The Plan says the documentation failed to prove that sufficient evidence 
of four-week trial of conservative therapy. 
 
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. Additionally, the documentation failed to prove that sufficient evidence of four-week trial 
of conservative therapy. 
 
 
 
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 preapprove intermittent limb compression 
device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for inpatient services provided from June 6, 
2020, to June 9, 2020, and from June 13, 2020, to June 15, 2020. 
 
You asked the Plan to waive the copayments for inpatient services. You say that the second admission was not 
your fault so there should not be any copayments. The Plan denied your request. The Plan says you were 
charged this coinsurance 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 $150 
copayment each day for days 1-7 per admission for Inpatient Hospital Care.  
 
You have been asked to pay a $150 copayment each day for 5 days of inpatient services. The inpatient services 
fall within the Inpatient Hospital Care 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 copayments for 
inpatient services provided from June 6, 2020, to June 9, 2020, and from June 13, 2020, to June 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system for a power wheelchair. 
 
You asked the Plan to pre-approve the requested item. The Plan denied your request. The Plan says the seat lift 
does not serve a medical purpose. 
 
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. Therefore, we 
decided that the Plan does not have to pre-approve a power seat elevation system for a power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient surgical services provided on 
May 18, 2020. 
 
You asked the Plan to waive the copayment for the outpatient surgical services. You say that you feel you 
should not be responsible for this copayment amount and you would like the Plan to reconsider your request. 
The Plan denied your request. The Plan says you received outpatient surgery in an outpatient hospital facility 
on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your 
contract with the Plan. 
 
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 per visit for Medicare-covered outpatient surgery or procedure at a hospital facility.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received outpatient 
surgical services on May 18, 2020. You have been asked to pay a $225 copayment for the outpatient surgical 
services. The outpatient surgical services fall within the Outpatient surgery 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 outpatient surgical services provided on May 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vision services provided on August 20, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the vision services. You say that you would not have went to this provider if you 
would have known they were out of network. The Plan denied your request. The Plan says that you must use 
network providers to get your medical care and services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the 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 vision services provided on August 20, 2020 
by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve flow cytometry for DNA or cell analysis for the 
enrollee. 
 
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no additional clinical information to show patients signs or symptoms, physical 
examination, or a different diagnosis. 
 
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 testing. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found no office notes were received except the lab slip checking off acute leukemia and lymphoma. In 
this case, there is inadequate information to process the request. There is no specific clinical rationale for the 
requested flow cytometry for DNA or cell analysis. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pre-approve flow cytometry for DNA or cell analysis for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgent care services provided. 
 
You asked the Plan to waive the copayment for the urgent care services. You say that your doctor's office 
would not give you an appointment so you had to go to Urgent Care. The Plan denied your request. The Plan 
says you were charged this copayment 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 $40 
copayment for Urgently Needed Services.  
 
You have been asked to pay a $40 copayment for the urgent care services. The urgent care services fall within 
the Urgently Needed 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 urgent care 
services provided.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve brain imaging, PET; metabolic evaluation (CPT Code 
78608 x1). 
 
You asked the Plan to pre-approve the PET scan. You say that the services are necessary. The Plan denied your 
request. The Plan says the services are not necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 the PET scan. Our physician reviewer 
found there is no clinical rationale for the requested PET scan. Per the documentation, the request can be 
approved if the records (office visit notes, test results, treatment) show the member meets criteria for the study. 
The review indicates that the member does not meet the criteria: 1.) To consider an item or service to be 
reasonable and necessary, if the service is appropriate, including duration and frequency that is considered 
appropriate for the item or service in terms whether it is furnished in accordance with acceptable standards of 
medical practice for the diagnosis of treatment of the patient's condition or to improve the function of a 
malformed body member. 2.) Metabolic positron emission tomography of the brain is used when your doctor 
needs to decide between Alzheimer's disease or frontotemporal dementia (a disease that affects your language 
and behavior). The neurologist does not believe that you have frontotemporal dementia. The requested PET 
scan is not medically necessary or reasonable. The review has determined that the medical records provided do 
not meet the requirements listed in the LCD/PIM for Medicare coverage. 
 
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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve brain imaging, PET; metabolic evaluation (CPT Code 78608 x1).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a CT scan of the abdomen and pelvis provided to the enrollee 
on May 20, 2020. 
 
You asked the Plan to pay for the scan. You say that this should be paid for. The Plan denied your request. The 
Plan says it cannot be determined that CPT code 74176 was performed during a separate/different session or 
for different clinical indications. 
 
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 74176 is "Computed tomography, abdomen and pelvis." 
 
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 the scan. Our reviewer says that the services 
at issue in this case were not supported by the medical records. Our physician reviewer found the enrollee had 
the same clinical symptoms and the reimbursement for the CT of the abdomen and pelvis should include both 
pre and post contrast evaluation of the abdomen and pelvis since the enrollee was being seen within only 2 
hours after the initial exam for the post contrast study. Hence the 2 CT abdomen and pelvis exams should be 
combined together for a CPT of 74178 rather than 2 separate charges. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pay for a CT scan of the abdomen and pelvis provided to the enrollee on May 20, 2020.