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

 
We decided that the Plan does not have to pre-approve an outpatient office visit and office consultation with an 
oral surgeon. 
 
You asked the Plan to pre-approve the outpatient office visit and consultation. You say that you are in pain and 
can only eat soft foods and soups. You also say that you have HTLV-1 which is causing your teeth to crumble 
and fall apart. The Plan denied your request. The Plan says the services you have requested are provided by a 
dentist. The Plan also says that your plan offers an optional dental benefit that would have covered your dental 
care, but you did not elect this option. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of your teeth or the structures directly supporting your teeth. The services you have requested are to be 
performed by an oral surgeon, and are dental in nature. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pre-approve an outpatient office visit and 
office consultation with an oral surgeon.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the facet injections rendered on December 2, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 64493 is 1. You billed 2 units each of code 64493-RT and 64493-LT, 
exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of these services 
have not been met. 
 
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 64494 is injection(s), diagnostic or therapeutic agent, 
paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or 
CT), lumbar or sacral; second level (List separately in addition to code for primary procedure). 
 
We find that CPT code 64494 is not supported in the medical record. Specifically, this is an add-on code and 
given that the primary procedure code 64493 is not payable, the add-on code is also not payable. 
 
Therefore, we decided that the Plan does not have to pay for the facet injections rendered on December 2, 
2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve specialist services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve specialist services. You say that you would like these services approved. 
The Plan denied your request. The Plan says there are in-network providers available for these services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers.  
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
specialist services to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
July 30, 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 July 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two gingival irrigations (D4921 x2) provided on June 26, 
2020. 
 
You asked the Plan to pay for the gingival irrigations. You say that you feel this service should be covered 
because of your diagnosis and being on a fluoride regiment. The Plan denied your request. The Plan says this 
service is not covered. 
 
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. 
 
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 pay for the two 
gingival irrigations (D4921 x2) provided on June 26, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on May 20, 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 physician services provided 
to the enrollee on May 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the simple extraction, two surgical extractions, and removal 
of residual tooth roots provided on February 26, 2020 by an OON provider. 
 
You asked the Plan to pay for the extractions and removal of residual tooth roots. You say that you were told 
that the Plan would cover services provided by this dental facility. The Plan denied your request. The Plan says 
these services were rendered by an OON provider. The Plan also says that no benefits are available for 
procedures performed by OON providers. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the simple 
extraction, two surgical extractions, and removal of residual tooth roots provided on February 26, 2020 by an 
OON provider.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve a transthoracic echocardiogram (TTE) with Doppler. 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the submitted evaluation note is not 
complete enough to assess the need for TTE, as the enrollee's specific complaints are not listed and there is no 
physical exam or blood pressure listed. A subsequent letter from the physician reports the enrollee is 
complaining of dyspnea and supine chest pain and his systolic blood pressure is poorly controlled. An 
assessment of left ventricular function and valvular disease is therefore reasonable using TTE. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve a transthoracic echocardiogram (TTE) with Doppler.  
 
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 a shower chair repairs. 
 
You asked the Plan to pre-approve a shower chair repairs. The Plan denied your request. The Plan says this 
item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair repairs.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the dental services provided from February 20, 
2020, to March 2, 2020. 
 
You asked the Plan to reimburse you for the dental services. You say that you were experiencing extreme pain 
in your mouth. You say that the dentist found an infection and prescribed antibiotics. You say that you 
understand that implants are not covered. You say that you have a dental allowance of $4,000 and some of it 
should be covered. The Plan denied your request. The Plan says that the provider in this case is not a network 
provider. The Plan also says that dental services that you receive out of network are not covered. 
 
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 dental services you receive out of 
network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
reimburse you for the dental services provided from February 20, 2020, to March 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided from January 31, 
2020, to February 15, 2020. 
 
You asked the Plan to pay for this service. You say that these services should be covered by the Plan. The Plan 
denied your request. The Plan says you 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 from January 31, 2020, to February 15, 2020.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve 77280, 77300 and 77412. We decided that the Plan does not have 
to pre-approve IGRT.  
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says there is no current research showing that the member's type of cancer responds better to 
the requested type of treatment than the type of treatment the Plan can approve. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. 
 
We decided that the Plan has to pre-approve 77280, 77300 and 77412.  
 
 
 
Our physician reviewer states that dry run simple simulation (CPT Code 77280), dose calculation for planning 
(77300) and treatment delivery (77412) are medically reasonable and necessary. Therefore, we decided that the 
Plan has to pre-approve 77280, 77330 and 77412.  
 
We also decided that the Plan does not have to pre-approve IGRT. 
 
Our physician reviewer says that image guided radiotherapy (IGRT) is a means of using of using daily image 
guidance to help localize the target so as to minimize normal tissue dosing. IGRT allows accuracy of treatment 
delivery, so when generating a planning target margin, the margins can be reduced, and thus allow reduction in 
the volume of normal tissues exposed to radiation. IGRT images can be obtained prior to treatment on a daily 
basis (interfraction IGRT), and/or before and during radiation (intrafraction IGRT). Daily CT imaging or kv-kv 
imaging, to verify position prior to every fraction, is an integrated feature with the LINAC used for this patient 
as described in the case records. Generally, it is used when there is a need to escalate the dose, and or use tight 
margins to adequately treat the target while sparing surrounding normal tissue. Our physician review found 
IGRT is not necessary. Therefore, we decided that the Plan does not pre-approve IGRT. 
 
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen/pelvis.
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 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of stage T1N0M0 breast cancer. Screening CT of abdomen and pelvis is not the standard of care for this stage of breast cancer. The services are 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 computed tomography (CT) scan of the abdomen/pelvis.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for telehealth services provided by a 
participating provider on April 27, 2020. 
 
You asked the Plan to waive the copayment for telehealth services. You say that this was a 5-minute phone 
call. The Plan denied your request. The Plan says telehealth services are still subject to copayments; therefore, 
the correct copayment has been 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 
physician/practitioner services for practitioner services/primary care provider.  
 
You have been asked to pay physician/practitioner services for telehealth services. Telehealth services fall 
within the practitioner services/primary care provider 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 provided by a participating provider on April 27, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from March 
13, 2020, to April 21, 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 claims were not billed with the UB-04 in order to establish the required home health 
agency (HHA). 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case the claim submitted cannot be paid as 
billed due to an omission of the appropriate codes. Medicare billing criteria are not met. Therefore, we decided 
that the Plan does not have to pay for home health services provided to the enrollee from March 13, 2020, to 
April 21, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the nervous system surgery 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 billed units of code 64999 are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 64999 is unlisted procedure, nervous system. 
 
We find that CPT code 64999 is not supported in the medical record. Specifically, there is no documentation to 
support the two units of this code. The records support only one unit of the code. 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 nervous system surgery rendered on February 4, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by Imperial Ambulance, 
Inc. on June 22, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on June 22, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided by Imperial 
Ambulance, Inc. on June 22, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services provided on July 
12, 2020. 
 
You asked the Plan to waive the copayment for the emergency room services. You say that you were not aware 
of the copayment responsibility since you never received the 2020 EOC handbook. You had abdominal pain 
and had to go to the emergency room to obtain immediate treatment. The Plan denied your request. The Plan 
says this claim was processed with the correct copayment applied per the plan benefits. 
 
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 $50 
copayment for Emergency care.  
 
You have been asked to pay $50 copayment for the emergency room services. the emergency room services 
fall within the Emergency 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 copayment for 
emergency room services provided on July 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe routine eye exam (92004) provided on August 14, 2020.You asked the Plan to pay forthe routine eye exam. You say that the second eye exam you received in the calendar year should be billed together with the first eye exam.The Plan denied your request. The Plan says the second routine vision exam you received exceeds the contract and you remain responsible for the charge.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. The Plan covers one non-Medicare covered routine vision exam per year.We looked at the file and the Plan's rules. The file indicates that the routine eye exam performed on August 14, 2020 was the enrollee's second routine eye exam of the year. The Plan covered the enrollee's first routine eye exam but the second routine eye exam exceeds the Plan's contractual obligation. Based on this information, we decided that the Plan's rules for coverage of the routine eye exam have not been met.Therefore, we decided that the Plan does not have to pay forthe routine eye exam (92004) provided on August 14, 2020.