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

 
We decided that the Plan does not have to pre-approve two surgical placements of implant bodies: endosteal 
implants (D6010 x2), two second stage implant surgeries (D6011 x2), two prefabricated abutments (D6056 x2), 
and two abutment supported porcelain/ceramic crowns (D6058 x2). 
 
You asked the Plan to pre-approve the endosteal implants, second stage implant surgeries, prefabricated 
abutments, and abutment supported crowns. You say that if nothing is done, there is a significant possibility of 
neighboring teeth being damaged. The Plan denied your request. The Plan says these services are not covered 
under your 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 two 
surgical placements of implant bodies: endosteal implants (D6010 x2), two second stage implant surgeries 
(D6011 x2), two prefabricated abutments (D6056 x2), and two abutment supported porcelain/ceramic crowns 
(D6058 x2).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on June 12, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
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 has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the services 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 the medical services provided to the enrollee by an out-of-network provider 
on June 12, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for needle electromyography studies (CPT 51785) provided to 
the enrollee on July 23, 2020. 
 
You asked the Plan to pay for the studies. You say that this should be paid for. The Plan denied your request. 
The Plan says the requested CPT code was not documented in the narrative of the operative report. 
 
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 51785 is "Needle electromyography studies." 
 
We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the studies. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our coding reviewer found the 
procedure report did not document that EMG of anal or urethral sphincter any technique was performed. All 
services provided should be clearly documented to verify services were performed. 
 
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 studies have not been met. Therefore, we decided that the Plan does not 
have to pay for needle electromyography studies (CPT 51785) provided to the enrollee on July 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on May 9, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was 
submitted after the timely filing limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services was not filed until June 10, 2020. This means that more than one 
calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan 
does not have to pay for the services provided on May 9, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services can be safely received in other settings, for example: a skilled nursing 
facility. 
 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for respiratory failure and COVID 19 pneumonia. Medical conditions are stable. There are no 
medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The 
enrollee does 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 this enrollee 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the debridements provided from July 16, 2020, to July 30, 
2020, by an OON provider. 
 
You asked the Plan to pay for the debridements. You say that network providers were not available at the 
enrollee's home. You also say that these services were urgently needed. The Plan denied your request. The Plan 
says these services were rendered by an OON provider. The Plan also says that prior 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 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 debridements provided from July 16, 2020, to 
July 30, 2020, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the needle electromyography services coded 95885, the 
nerve conduction studies coded 95908, and the neuromuscular junction testing coded 95937 provided on July 
10, 2020. 
 
You asked the Plan to pay for the needle electromyography services, the nerve conduction studies, and the 
neuromuscular junction testing. 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 supported by the documentation. 
 
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 95885, 95908 and 95937 are not supported in the medical record. Specifically, the 
technical report did not include documentation of a limited needle electromyography, per each extremity with 
related paraspinal areas when performed, done with nerve conduction, amplitude and latency/velocity study; 
(listed separately in addition to code for primary procedure); therefore, code 95885 cannot be verified.  
The technical report did not include documentation of nerve conduction studies, for 3-4 studies; therefore, code 
95908 cannot be verified. The technical report did not include documentation of neuromuscular junction testing 
(repetitive stimulation, paired stimuli) for each nerve, by any 1 method; therefore, code 95937 cannot be 
verified. Based on this information, we decided that Medicare rules for coverage of the needle 
electromyography services, the nerve conduction studies, and the neuromuscular junction testing have not been 
met. Therefore, we decided that the Plan does not have to pay for the needle electromyography services coded 
95885, the nerve conduction studies coded 95908, and the neuromuscular junction testing coded 95937 
provided on July 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee is non-compliant with the glucometer, and with testing of blood glucose. 
 
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found you are reported to have type II diabetes, for which she takes oral medication.  There is no evidence that 
you use insulin. You are ordered to test your blood glucose twice a day. It is unclear how often you are testing 
your blood glucose. There is no evidence that you use the results of blood glucose testing to self-adjust the dose 
of insulin multiple times per day. Therefore, the requested monitor is not shown to be medically necessary or 
reasonable. 
 
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 pre-approve a continuous glucose monitor.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for hernia repair surgery provided. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you paid for the first surgery 
and should not have to pay for this second surgery. The Plan denied your request. The Plan says the copayment 
amount you are being charged is correct. 
 
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 $250 
copayment for in-network outpatient surgery at an outpatient hospital.  
 
You have been asked to pay $250 copayment for outpatient surgery. Outpatient surgery falls within the 
Outpatient Surgery, Including Services Provided at Outpatient Hospital 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 hernia repair surgery 
provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ski membership you purchased on September 27, 2020. 
 
You asked the Plan to pay for the ski membership. The Plan denied your request. The Plan says this is not a 
covered benefit. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. The Plan covers gym benefits 
only in a qualified health club or fitness facility. 
 
The Plan?s rules for coverage of gym benefits have not been met because a ski club is a non-qualified facility. 
Therefore, we decided that the Plan does not have to pay for the ski membership you purchased on September 
27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the 4Kscore testing provided on June 17, 2020. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not covered. 
 
The Plan follows Medicare rules. Medicare rules say that 4Kscore testing is covered when the above criteria 
are met. 
 
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 testing. Our reviewer says that the 
requested 4Kscore testing is not medically reasonable and necessary. Our physician reviewer found that the 
enrollee is a 76-year-old male with elevated PSA of 6.38 ng/mL. The enrollee has not had a prostate biopsy. 
The requested 4Kscore testing is not medically reasonable and necessary according to the coverage criteria 
established in the above LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the testing have not been met. Please note that the LCD referenced by the Plan 
is not applicable for the jurisdiction in question. Therefore, we decided that the Plan does not have to pay for 
the 4Kscore testing provided on June 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for a ski pass provided on September 29, 2020. 
 
You asked the Plan to reimburse you for the ski pass. You say that due to COVID-19 there was no access to a 
gym or health facility, so the ski resort was the only option at that time. The Plan denied your request. The Plan 
says a ski pass is not part of a qualified health club or fitness facility for the Wellness Allowance benefit. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
The Plan?s rules for coverage of gym benefits have not been met because a ski pass is not part of a qualified 
health club or fitness facility for the Wellness Allowance benefit. Therefore, we decided that the Plan does not 
have to reimburse you for a ski pass provided on September 29, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MRI of the thoracic and lumbar spine. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no information about prior x-rays. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found the enrollee reports 
complaints of severe back pain and a right shoulder lump. She reported she had annual MRI testing. Clinical 
exam findings from August through December 2020 did not evidence a shoulder/upper back physical exam, or 
upper or lower extremity neurologic exam. Under consideration is a request for thoracic and lumbar spine MRI. 
Current evidence based medical guidelines and literature recommends immediate imaging for patients with 
major risk factors for cancer, spinal infection, cauda equina syndrome, or severe or progressive neurologic 
deficits. Imaging after a trial of treatment is recommended for patients who have minor risk factors for cancer, 
inflammatory back disease, vertebral compression fracture, radiculopathy, or symptomatic spinal stenosis. 
There is no specific indication documented by the requesting physician to support the medical necessity of 
imaging. There is no clinical evidence to support the medical necessity of repeat imaging at this time. Detailed 
evidence of a recent, reasonable and/or comprehensive non-operative treatment protocol trial and failure has 
not been submitted. There is no indication of new symptoms or change in current symptoms to support repeat 
imaging. There is no compelling rationale presented or extenuating circumstances noted to support the medical 
necessity of this request. Therefore, this request for MRI of the thoracic and lumbar spine is not 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 the MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve MRI of the thoracic and lumbar spine.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided on July 13, 2020. 
 
You asked the Plan to waive the copayment for an MRI. You say that you had already had a previous MRI and 
do not feel this one was necessary. You also state that the results were botched. 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 $95 
copayment for each radiological diagnostic service.  
 
You have been asked to pay a $95 copayment for an MRI. An MRI falls within the outpatient diagnostic tests 
and therapeutic services and supplies 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 MRI provided on July 13, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance trip provided by a 
participating provider on August 20, 2020. 
 
You asked the Plan to waive the copayment for an ambulance trip. You say that you were supposed to take a 
taxi but there would not taxis available. You say that this is why the ambulance was called. 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 $300 
copayment for ambulance services.  
 
You have been asked to pay $226.18 which is less than your copayment amount of $300 for an ambulance trip. 
An ambulance trip falls within the ambulance services benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for an ambulance trip provided by a participating provider on August 20, 2020.  
 
We note your complaint about having to call the ambulance because there were no taxis available. Your 
complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for eyeglasses provided on September 11, 2020. 
 
You asked the Plan to reimburse you for the eyeglasses. The Plan denied your request. The Plan says the 
upgraded items of progressive lenses, tinting and anti-reflection coating was denied as these are not covered 
services. 
 
Medicare generally does not cover eyewear services. The contract with the Plan says the Plan does not pay for 
the upgraded items of progressive lenses, tinting and antireflection coating. 
 
We looked at the file, Medicare?s rules and the Plan's rules. The Plan does not cover upgraded items of 
progressive lenses, tinting and anti-reflection coating. Therefore, we decided that the Plan does not have to 
reimburse you for eyeglasses provided on  
September 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic (D6241) and retainer crown (D6751). 
 
You asked the Plan to pre-approve the pontic and retainer crown. You say that you would like to appeal this 
claim because you live on social security, and cannot work. 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 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 
pontic (D6241) and retainer crown (D6751).