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

 
We decided that the Plan does not have to pay for computed tomography angiography of the chest (CPT 
71275) provided to the enrollee on September 3, 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 the claim was billed with place of service 22 - outpatient. 
 
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 71275 is "computed tomography angiography, chest 
(noncoronary) with contrast material(s), including noncontrast images, if performed, and image post 
processing." 
 
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 
services at issue in this case were not supported by the medical records. Our physician reviewer found the 
documentation submitted supports the enrollee was an inpatient for the dates of service at issue in this case. 
Therefore, it is inappropriate to bill a service for an outpatient. 
 
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 computed tomography angiography of the chest (CPT 71275) provided to the enrollee on 
September 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for medical supplies (S1015, S8301) provided on May 18, 2020. 
 
You asked the Plan to pay for medical supplies. You say that this should be covered. The Plan denied your 
request. The Plan says these codes are not valid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes S1015 and S8301 are not supported in the medical record. Specifically, these codes 
have a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. 
Based on this information, we decided that Medicare rules for coverage of medical supplies have not been met. 
Therefore, we decided that the Plan does not have to pay for medical supplies (S1015, S8301) provided on May 
18, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entyvio 1 mg injection (J3380). 
 
You asked the Plan to pre-approve Entyvio. You say that this drug is medically necessary to treat the enrollee's 
condition. The Plan denied your request. The Plan says step therapy criteria has not been met. 
 
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 Entyvio. Our reviewer says that this 
service is not medically necessary and reasonable. Our physician reviewer found The Plan's step therapy 
alternative, Stelara, is FDA-approved, and is indicated pertinent to the enrollee's case, for Adult patients with 
moderately to severely active Crohn's disease (CD) who have failed or were intolerant to treatment with 
immunomodulators or corticosteroids. However, the available records do not support a unique clinical 
circumstance that warrants a medically necessary Plan policy exception for coverage of Entyvio prior to trial 
and failure of Plan-preferred Stelara. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Entyvio have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Entyvio 1 mg injection (J3380).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Hyperbaric Oxygen therapy services 
(G0277) provided from October 14, 2019, to November 7, 2019. 
 
You asked the Plan to waive the copayment for Hyperbaric Oxygen therapy services. You say that you thought 
the service was covered and you would not have to pay for it. The Plan denied your request. The Plan says the 
services were covered, but there is a $295 copayment for each Medicare covered surgery or other services 
provided to you at an outpatient hospital setting. The Plan states that you received sixteen days of Hyperbaric 
Oxygen therapy services, and that the maximum out-of-pocket cost to you for these services is $5,000. 
 
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 $295 
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical centers, with a maximum cost to you of $5,000. 
 
You have been asked to pay a $295 copayment for Hyperbaric Oxygen therapy services, or a total of 4,525 for 
sixteen days of services. Hyperbaric Oxygen therapy falls within the outpatient surgery and other medical 
services provided at hospital outpatient facilities and ambulatory surgical centers. 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 Hyperbaric Oxygen therapy services (G0277) provided from October 14, 2019, to 
November 7, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the fixed partial denture sectioning (D9120) provided on 
September 2, 2020. 
 
You asked the Plan to pay for the dental service. You say that you had to have a tooth pulled. You say that your 
bridge is on top of it. You say that the provider in this case cut the bridge off because the oral surgeon did not 
have the tools. The Plan denied your request. The Plan says the fixed partial denture sectioning is not listed as a 
covered service. The Plan also says that any services not listed 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 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 fixed 
partial denture sectioning (D9120) provided on September 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lower partial denture (D5214) provided on March 11, 
2020. 
 
You asked the Plan to pay for the dental service. You say that you have diabetes. You say that your gums were 
weak and not able to support your teeth. You say that your teeth began to loosen and you were not able to eat 
or bite on food. You also say that the service was necessary. The Plan denied your request. The Plan says your 
policy only offers dental coverage for preventive services. The Plan also says that the partial denture is not 
listed as a preventive service. 
 
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 lower 
partial denture (D5214) provided on March 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99328, G0506) provided on September 
25, 2020. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the services were not emergent. There were network providers 
available. 
 
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 had network providers 
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service 
at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided 
that the Plan does not have to pay for physician services (99328, G0506) provided on September 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D1999, D5640, D5512). 
 
You asked the Plan to pre-approve the services. You say that you cannot afford this. The Plan denied your 
request. The Plan says these are not covered codes. 
 
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 
dental services (D1999, D5640, D5512).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says a review of the current medical literature indicates that this service is considered 
experimental and investigational. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the spacer is experimental. More research is needed to show safety and efficacy. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a post and core in addition to crown (D2952). 
 
You asked the Plan to pre-approve the post and core. You say that the enrollee has a missing tooth next to tooth 
#22, and would like to replace it with a splinted crown procedure. The Plan denied your request. The Plan says 
this service is not covered under the enrollee's benefit package. 
 
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 
post and core in addition to crown (D2952).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on June 16, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics 
with taking only your vitals. 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 16, 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 on June 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve laparoscopic repair of prolapsed vagina for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the enrollee does not meet criteria for repair of pelvic organ 
prolapse. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. There is no 
documentation of pelvic organ prolapse on physical exam. There is no justification in the medical record for a 
uterosacral ligament suspension at the time of hysterectomy. Our physician reviewer found that the enrollee's 
condition does not meet criteria for coverage of these services. 
 
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 laparoscopic repair of prolapsed vagina for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network provider for an office 
visit. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are in-network providers available. 
 
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 
a referral to an out-of-network provider for an office visit.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a cystourethroscopy provided on 
September 14, 2020. 
 
You asked the Plan to waive the copayment for a cystourethroscopy. You say that you did not pay a facility fee 
in the past and disagree with the charges. The Plan denied your request. The Plan says the claims were 
processed correctly and you are being charged the correct 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 $500 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
You have been asked to pay a $500 copayment for a cystourethroscopy. A cystourethroscopy falls within the 
outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 
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 cystourethroscopy provided on 
September 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a 
participating provider on January 24, 2020. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you cancelled your health 
plan in January. The Plan denied your request. The Plan says 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 a $50 
copayment for physician/practitioner services/specialist.  
 
You have been asked to pay a $50 copayment for a specialist office visit. The correct copayment has been 
applied to this office visit. A specialist office visit falls within the physician/practitioner services/specialist 
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 specialist office visit provided 
by a participating provider on January 24, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Novolog injection, 100 ml. 
 
You asked the Plan to pre-approve Novolog injection. You say that the Novolog will not be injected via pump 
or subcutaneous pump. The Plan denied your request. The Plan says the requested drug is considered self-
administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug 
plan. The Plan also says the requested drug is not covered under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Novolog injection, 100 ml.  
 
Benefits for Novolog injection 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you have fallen many times in the tub. The 
Plan denied your request. The Plan says this is not a covered benefit, as it is a comfort/convenience item. 
 
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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wrist hand orthosis provided on August 4, 2020. 
 
You asked the Plan to pay for the wrist hand orthosis (L3916). You say that the Plan should pay this claim. The 
Plan denied your request. The Plan says the medical records submitted did not include a face-to-face encounter 
within the last 6 months. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket 
does not have the tracking number on it and the Proof of Delivery does not have a description of the items 
delivered. Therefore, we decided that the Plan does not have to pay for the wrist hand orthosis provided on 
August 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care (99308) to be 
provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve the SNF care. You say that you prefer the OON SNF care due to failure to 
thrive at other facilities. The Plan denied your request. The Plan says they have multiple in-network facilities 
able to provide the care you need. 
 
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 
the skilled nursing facility (SNF) care (99308) to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of a Superion interspinous stabilization 
device (22869, 22870). 
 
You asked the Plan to pre-approve this service. You say that this service is medically necessary as the enrollee 
has lumbar spinal stenosis. The Plan denied your request. The Plan says this service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve this service. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the spacer device is experimental. More research is needed to show safety and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the insertion of a Superion interspinous stabilization device (22869, 22870).