Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve Injection Facet cervical, bilateral. 
 
You asked the Plan to pre-approve Injection(s), diagnostic or therapeutic agent, paravertebral facet 
(zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or 
thoracic; single level (64490). You say that the enrollee needs cervical facet injections for management of 
cervical pain and cervicogenic vertigo. The Plan denied your request. The Plan says that the evidence does not 
currently support that facet injections have been demonstrated to have an effect on improving long term patient 
outcome. 
 
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 Injection(s), diagnostic or therapeutic 
agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance 
(fluoroscopy or CT), cervical or thoracic; single level (64490). Our reviewer says that the requested 
items/services are considered medically reasonable and necessary in this case. Our physician reviewer found 
this request is for facet injections to treat a rare condition called cervicogenic vertigo, not facet joint syndrome. 
The requested procedure is medically reasonable and 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 Injection(s), diagnostic or therapeutic agent, paravertebral facet 
(zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or 
thoracic; single level (64490) have been met. Therefore, we decided that the Plan has to pre-approve Injection 
Facet cervical, bilateral.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for TMVR (33418) provided on May 22, 2020. 
 
You asked the Plan to pay for the TMVR. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the claim was not submitted with a valid clinical trial 
number. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 33418 is not supported in the record. Specifically, the clinical trial number included on 
the claim is not listed on the Medicare website for this service. Based on this information, we decided that 
Medicare rules for coverage of the TMVR have not been met. Therefore, we decided that the Plan does not 
have to pay for TMVR (33418) provided on May 22, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says medical studies have not proven that this service is helpful for treatment of chronic 
low back pain. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Intracept procedure remains experimental for the treatment of degnerative low back pain. 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral X-ray (D0220) provided on September 15, 
2020. 
 
You asked the Plan to pay for the intraoral X-ray. You say that your X-ray should be covered under your 
policy. The Plan denied your request. The Plan says this service is not a covered benefit under your dental 
benefit. 
 
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 
intraoral X-ray (D0220) provided on September 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cancer treatment to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve cancer treatment to be provided by an OON provider. You say that the 
services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able 
to provide this care. Therefore, coverage criteria has not been met. 
 
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 
cancer treatment to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a 
participating provider on February 9, 2020, to February 12, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you do not agree with 
this copayment. 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 $285 
copayment per day for days 1-6. There is a $0 copayment for additional days for inpatient hospital care.  
 
You have been asked to pay a $285 copayment per day for days 5-6 for an inpatient hospital stay. The total 
amount you are being asked to pay is $570 ($285 x 2 days = $570). This inpatient stay was a continuation of a 
previous inpatient stay; therefore, the correct copayment has been applied. An inpatient hospital stay falls 
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 copayment for 
an inpatient hospital stay provided by a participating provider on February 9, 2020, to February 12, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that you would like the plan to reconsider their denial. The 
Plan denied your request. The Plan says the requested drug is not medically necessary. 
 
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 Prolia. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has a history of osteoporosis. The documentation does not support that the enrollee 
has tried and failed Zoledronic Acid. There is no documentation provided indicating that the Plan's required 
drug would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the enrollee 
does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mammogram (77065) provided August 21, 2020. 
 
You asked the Plan to pay for the mammogram. You say that the copayment should be waived. The Plan 
denied your request. The Plan says this was a diagnostic mammogram and not a screening mammogram. The 
correct copayment was 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 $130 
copayment for x-rays.  
 
You have been asked to pay the allowable copayment of $109.69 for the mammogram. The mammogram falls 
within the x-rays benefit category. The copayment applied is less than the $130 noted in the plan contract. 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 pay for a mammogram (77065) provided August 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waivethe $15 copayment charged for oxygen equipment provided on March 7, 2020.You asked the Plan to waivethis copayment. You say that you do not have this equipment and the Plan should not pay for it. You say that you are not paying the copayment.The Plan denied your request. The Plan says this copayment was charged based on the claim submitted by the provider. The Plan paid its portion of this claim leaving the copayment owed to the provider.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 20% coinsurancefor durable medical equipment. You have been asked to pay the correct amount based on your contract with the Plan. Any issues regarding the equipment or the copayment are between you and the provider as the Plan has made payment based on claims from the provider. 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 waivethe $15 copayment charged for oxygen equipment provided on March 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on September 11, 2020. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says dental services must be provided by a 
participating provider in order to be covered by the Plan. 
 
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 received in this case 
are not among those covered under this benefit as they were provided by a non-participating provider. 
Therefore, we decided that the Plan does not have to pay for the dental services provided on September 11, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device provided to the enrollee on 
July 9, 2020. 
 
You asked the Plan to pay for this equipment. You say that the Plan should pay for this equipment. The Plan 
denied your request. The Plan says Medicare coverage criteria for this type of equipment are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that plans can require enrollees to get prior 
authorization. Medicare has specific coverage criteria for the type of equipment provided. The Plan contract 
states that durable medical equipment requires prior authorization. The records provided do not show the 
enrollee had prior authorization for this equipment. The records provided do not show the enrollee meets the 
Medicare criteria required for this equipment.  Therefore, we decided that the Plan does not have to pay for a 
pneumatic compression device provided to the enrollee on July 9, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $35 copayment charged for therapy services provided on 
July 1, 2020. 
 
You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The 
Plan denied your request. The Plan says this copayment was charged based on the services provided and the 
Plan contract agreement. 
 
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 $35 
copayment for outpatient therapy. 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 $35 copayment charged for therapy services 
provided on July 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a complete maxillary and mandibular denture (D5110 and 
D5120) received on August 17, 2020. 
 
You asked the Plan to pay for the dentures. You say that you have a benefit for this. The Plan denied your 
request. The Plan says there is no coverage for this service. 
 
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 a 
complete maxillary and mandibular denture (D5110 and D5120) received on August 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from June 26, 
2020, to June 30, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you feel that you were 
discharged from a previous stay too early 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 $400 
copayment for days 1-4 for inpatient hospital care.  
 
You had an inpatient hospital stay from June 26, 2020, to June 30, 2020. Therefore, you are responsible to pay  
$1,200, which is less than the total copayment amount.   
 
You have been asked to pay $1,200 for an inpatient hospital stay. An inpatient hospital stay falls 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 copayment for an inpatient 
hospital stay from June 26, 2020, to June 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic casts (D0470) provided on September 15, 
2020. 
 
You asked the Plan to pay for the dental service. You say that the service was medically necessary. The Plan 
denied your request. The Plan says diagnostic cast is not listed as a covered 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. The Evidence of Coverage clearly states that any services not listed are 
not covered. Therefore, we decided that the Plan does not have to pay for the diagnostic casts (D0470) 
provided on September 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on July 14, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for clinic visit. You say that you have a right to recover payment from the Plan for 
this service. The Plan denied your request. The Plan says the denial of payment for this service is correct, 
because this provider is out-of-network with the Plan and authorization was not obtained. 
 
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 medical services provided on July 14, 2020 by 
an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that you have problems with your gait, and have 
increased falling. The Plan denied your request. The Plan says you do not meet any of the exceptions 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 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 OON services. Therefore, we decided that the Plan does not have to pre-approve 
physical therapy services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve OON services. The Plan denied your request. The Plan says there are 
doctors in the plan that can give the care the enrollee needs. 
 
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 OON services. Therefore, we decided that the Plan does not have to pre-approve 
medical services to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for open femoral artery exposure (34812 AS LT and 34812 AS 
RT) provided on July 20, 2020. 
 
You asked the Plan to pay for the open femoral artery exposure. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says if the bilateral surgery indicator is 
"1", a bilateral surgical procedure must be reported with "1" UOS and modifier 50 (bilateral modifier). 
 
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, CPT code 34812 has a bilateral surgical indicator of 1. 
 
We find that CPT codes 34812 AS LT and 34812 AS RT are not supported in the record. Specifically, CPT 
code 38412 has a bilateral surgical indicator of 1. This means that this CPT code must be reported with 1 unit 
of service and modifier 50 to indicate the bilateral procedure. Based on this information, we decided that 
Medicare rules for coverage of the open femoral artery exposure have not been met. Therefore, we decided that 
the Plan does not have to pay for open femoral artery exposure (34812 AS LT and 34812 AS RT) provided on 
July 20, 2020.