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

We decided that the Plan has to pay for the extractions provided on August 31, 2020. 
 
You asked the Plan to pay for the extractions. You say that these are accurate diagnosis codes for this type of 
procedure. You say that the claim should be reprocessed as it was billed correctly. The Plan denied your 
request. The Plan says that the services are not covered benefits. 
 
The Plan follows Medicare rules. Medicare rules say that the extraction of teeth to prepare the jaw for radiation 
treatment of neoplastic disease is 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 extractions. Our reviewer says that the 
criteria for coverage has been met. Our physician reviewer found that in the case of squamous cell carcinoma 
involving the supraglottic area of the throat as well as the larynx, the jaw would be impacted by radiation 
therapy. Our reviewer says that the extraction of teeth to prepare the jaw for radiation treatments of neoplastic 
disease is covered. 
 
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 extractions have been met. Therefore, we decided that the Plan has to pay 
for the extractions provided on August 31, 2020.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need the level of care that an IRF provides. The 
Plan denied your request. The Plan says rules for IRF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not require treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents 
a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation 
program. 
 
There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endodontic therapy (D3310), denture re-cementing 
(D6930), and gingivectomy (D4211). 
 
You asked the Plan to pre-approve endodontic therapy, denture re-cementing, and gingivectomy. You say that 
your dentist says you need these services. The Plan denied your request. The Plan says these services 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 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 pre-approve 
endodontic therapy (D3310), denture re-cementing (D6930), and gingivectomy (D4211).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Escitalopram Tablet. 
 
You asked the Plan to pre-approve Escitalopram Tablet. You say that you want the enrollee treated with this 
drug. The Plan denied your request. The Plan says this drug is not covered under the enrollee's Medicare Part B 
benefit. 
 
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 Escitalopram Tablet.  
 
Benefits for Escitalopram Tablet 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a new patient chiropractic visit (CPT 99204). 
 
You asked the Plan to pre-approve the visit. The Plan denied your request. The Plan says this is not a covered benefit. 
 
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 service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pre-approve a new patient chiropractic visit (CPT 99204).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Darsalex Faspro for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the off-label use of this drug is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that the 
requested drug is medically reasonable and necessary. Our physician reviewer found this is FDA-approved in 
combination with lenalidomide which is part of plan but treating physician wants to start 1 medication at a 
time. The requested drug is safe and effective and otherwise reasonable and necessary for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the drug have been met. Therefore, we decided that the Plan has to pre-approve 
Darsalex Faspro for the enrollee.  
 
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the nerve conduction studies (95910) 
provided on August 31, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $25 
copayment for Medicare-covered non-radiological diagnostic services.  
 
You have been asked to pay a $25 copayment for the Medicare-covered diagnostic service provided. 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 nerve conduction studies (95910) provided on  
August 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve total electric hospital bed. You say that you desperately need this because 
the you cannot move your arms or legs and needs help to be lifted out of the bed. Your wife cannot move you 
because she cannot support your weight. 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 a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve total electric hospital 
bed (E0265).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sales tax (S9999) provided on February 27, 2020. 
 
You asked the Plan to pay for the sales tax (S9999). You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says they have overturned their denial of payment 
for the chiropractic services; however, the sales tax is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say contractors do not make any additional payment for sales 
taxes. 
 
We looked at the file and Medicare rules. In this case, the Plan has approved payment for the chiropractic 
services provided from January 2, 2020 to February 27, 2020. However, Medicare does not make separate 
payment for sales tax. Therefore, we decided that the Plan does not have to pay for the sales tax (S9999) 
provided on February 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair glide. 
 
You asked the Plan to pre-approve a stair glide. You say that you are wheelchair bound and unable to go up the 
stairs to shower. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift 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 stair glide.
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 your unable to stand in the shower by yourself. 
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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing (G0481, 80307) provided on February 25, 
2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for OON drug testing. You say that this was medically necessary. The Plan denied 
your request. The Plan says this was not authorized. 
 
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 drug testing (G0481, 80307) provided on 
February 25, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the blood glucose monitor supplies provided on June 9, 
2020. 
 
You asked the Plan to pay for the blood glucose monitor supplies. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
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. Review of the file 
shows that the documentation submitted did not include an itemized shipping/billing invoice to indicate the 
specific supplies or proof of delivery. The record shows that the Plan made several attempts to obtain the 
necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the 
blood glucose monitor supplies provided on June 9, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services provided on July 7, 2020. 
 
You asked the Plan to pay for the outpatient hospital services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says Medicare payment can only be 
made to Indian Health Service facilities when the proper billing rules are followed. 
 
The Plan must follow Medicare rules. Medicare rules say that IHS facilities must bill using revenue code 0510 
for outpatient services billed to Medicare. 
 
In this case, the correct revenue code was not used for IHS Medicare billing. Therefore, we decided that the 
Plan does not have to pay for the outpatient hospital services provided on July 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve adult probiotics. 
 
You asked the Plan to pre-approve the probiotics. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not a covered item according to the OTC catalog. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the 
probiotics are an OTC item. However, the plan does provide a supplemental benefit for certain OTC items. 
Adult probiotics are not one of the plan-approved OTC items. Therefore, we decided that the Plan does not 
have to pre-approve adult probiotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that this should be covered because it is 
medically necessary. The Plan denied your request. The Plan says incontinence garments of any type, such as a 
incontinence pads and disposable bed pads, are excluded from coverage because they are non-reusable, 
hygienic items. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pregabalin for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this has worked well for the enrollee. The Plan 
denied your request. The Plan says that this is not covered under 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 Pregabalin for the enrollee.  
 
Benefits for this drug 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the triamcinolone acetonide injection (J3301) provided on 
July 28, 2020. 
 
You asked the Plan to pay for the injection. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the documentation does not support the service billed. 
 
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 J3301 is injection, triamcinolone acetonide, not otherwise 
specified, 10 mg. 
 
We asked our coder 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 injection. Our reviewer says that CPT code J3301 does 
not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided 
do not include sufficient documentation to corroborate an injection, triancinolone acetonide, not otherwise 
specified, 10mg was performed on July 28, 2020, therefore this service cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not 
have to pay for the triamcinolone acetonide injection (J3301) provided on July 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical assistant services received on July 10, 2020, and 
July 27, 2020. 
 
You asked the Plan to pay for the services. You say that you were unaware that an assistant surgeon was 
involved. The Plan denied your request. The Plan says reimbursement for an assistant surgeon is not 
recommended. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT code 
64721. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means 
that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based 
upon this information, we find that Medicare coverage criteria for the services have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that items and services that are not medically necessary 
are not covered. Medicare rules say that for procedures with an assistant surgery indicator of 0, the payment 
restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to 
establish medical necessity.  
 
 
 
 
 
In this case, you billed assistant surgery services for CPT code 64718. The Medicare Fee Schedule Database 
contains a surgical indicator of 0 for this procedure. Our reviewer found that an assistant surgeon was not 
medically necessary for this procedure. Therefore, we decided that the Plan does not have to pay for surgical 
assistant services received on July 10, 2020, and July 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for comprehensive eye exam (92014) scanning 
computerized ophthalmic diagnostic imaging (92134) and refraction services (92015) provided July 6, 2020. 
 
You asked the Plan to waive the copayment for the vision services. You say that you had an eye exam and the 
plan paid for the his office visit but not for the extra $30 he charged. The Plan denied your request. The Plan 
says this claim processed and the correct copayment was applied per the Evidence of Coverage. 
 
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 $30 
copayment for Medicare covered vision services in a specialist's office.  
 
You have been asked to pay $30 copayment for the vision services. The vision services fall within the Vision 
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 comprehensive eye exam 
(92014) scanning computerized ophthalmic diagnostic imaging (92134) and refraction services (92015) 
provided July 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee on July 15, 
2020, by an out-of-network provider. 
 
You asked the Plan to pay for the medical services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services were not referred by a network provider or rendered in a participating 
facility and these services are not urgent or emergent, nor were they approved In advance. 
 
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 items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee on 
July 15, 2020, by an out-of-network provider.