Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a leadless pacemaker for the enrollee. 
 
You asked the Plan to pre-approve the pacemaker. You say that this is medically necessary. The Plan denied 
your request. The Plan says this 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 pacemaker. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in this circumstance treatment with the Optimizer System (CPT0408T) device has been 
demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy. 
Moreover, the trial was very small (only 160 patients) and the results for the composite endpoint barely reached 
statistical difference (p=0.048).  Therefore the efficacy of the Optimizer System (CPT 0408T) is still uncertain 
at this time according to leading authorities and not recommended in current guidelines for the treatment of 
heart failure. Medicare coverage criteria are not met since the device should still be considered experimental or 
investigational. 
 
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 pacemaker have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a leadless pacemaker for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for specialist services provided on January 1, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for specialist services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The 
Plan says that there are in-network providers available for these services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 specialist services provided on January 1, 2020 by 
an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the imaging services rendered on 
September 25, 2019 to March 5, 2020. 
 
You asked the Plan to waive the copayments for these services. You say that you have already paid the 
copayments. The Plan denied your request. The Plan says the copayments were applied correctly. 
 
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 Medicare-covered diagnostic radiology services at an outpatient hospital.  
 
Review of the file shows that you received diagnostic radiology services from September 25, 2019 to March 5, 
2020. You have been asked to pay a $300 copayment per date of service for these services. These services fall 
within the Medicare-covered diagnostic radiology services at an outpatient hospital 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 copayments for the imaging services rendered on September 25, 2019 to 
March 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection services provided to the enrollee on June 9, 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 these codes have a MAI indication of "2" and the allowable units of service on the same date of 
service is an MUE value of 1. 
 
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 the denied codes is: 
 
CPT 64493: 
 
Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (ornerves innervating 
that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level. 
 
CPT 64494: 
 
Injection(s),diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating 
that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (List separately in addition 
to code for primary procedure) 
 
CPT 64495: 
 
Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating 
that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s) (List 
separately in addition to code for primary procedure) 
 
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 
enrollee received bilateral facet joint injections at three levels.  Bilateral injections should be billed using the 
modifier 50, rather than billing for each side using RT and LT modifiers. As such, the health plan is correct to 
pay only for one set of billed injections (RTs) and to deny the second set of billed injections (LTs), as the 
 
 
second billing should have been included in the first with the 50 modifier. 
 
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 injection services provided to the enrollee on June 9, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency room (ER) services you 
received on July 10, 2020. 
 
You asked the Plan to waive the copayment for the ER services. You say that you shouldn't have to pay a 
copayment because the ER doctor told you that you needed to see a specialist. The Plan denied your request. 
The Plan says you were charged this copayment correctly. 
 
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 $100 
copayment for visits to the emergency room.  
 
You have been asked to pay a $100 copayment for the ER services. This copayment applies regardless of your 
satisfaction with the visit. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for emergency room (ER) 
services you received on July 10, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging of the breast. 
 
You asked the Plan to pre-approve a breast MRI. You say that you have a strong family history of breast 
cancer. The Plan denied your request. The Plan says there has not been a follow up diagnostic mammogram 
first. 
 
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 a breast MRI. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found no clinical breast exam is included in the 
submitted documentation. The NCCN Guidelines Version 1.2020 Breast Cancer Screening and Diagnosis page 
BSCR-5 recommends diagnostic mammogram and ultrasound for palpable mass over age 30. Therefore a 
breast MRI is not 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 a breast MRI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a magnetic resonance imaging (MRI) of the breast.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided to the enrollee on June 5, 
2020. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says coverage extends only to treatment by means of manual manipulation of the spine to 
correct a subluxation. 
 
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 pay for chiropractic services provided to the enrollee on June 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on June 12, 2020. 
 
You asked the Plan to pay for the dental service. You say that you were not aware that bitewing x-rays had a 
different frequency limit than an exam and cleaning. The Plan denied your request. The Plan says bitewing x-
rays are covered once in a 12 month period. The Plan says that the frequency limit has been exceeded. 
 
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 frequency limit has been exceeded. 
The record shows that the Plan paid for bitewing x-rays that you received on July 16, 2019, less than 12 months 
prior. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on 
June 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two bone grafts at the time of implant placements 
(D6104 x2). 
 
You asked the Plan to pre-approve the bone grafts. You say that you cannot afford to pay for the bone grafts. 
The Plan denied your request. The Plan says this service is not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 
bone grafts at the time of implant placements (D6104 x2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete series of intraoral x-rays provided on July 8, 
2020. 
 
You asked the Plan to pay for the complete series of intraoral x-rays. You say that you contacted the Plan prior 
to having the service rendered, and were told it would be covered. The Plan denied your request. The Plan says 
the benefits for this service have been satisfied and the frequency limitation has been exceeded. 
 
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, intraoral x-rays are limited to one 
procedure per calendar year. The record shows that you received a complete series of intraoral x-rays on 
September 11, 2019, and your intraoral x-rays benefit has been exhausted. Therefore, we decided that the Plan 
does not have to pay for the complete series of intraoral x-rays provided on July 8, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Trulicity injection, 1. mg, once per week. 
 
You asked the Plan to pre-approve Trulicity. You say that this drug will help to lower the enrollee's blood sugar 
levels. 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 drug 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 a Trulicity injection, 1. mg, 
once per week.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Panther 22CS scooter. 
 
You asked the Plan to pre-approve the scooter. You say that this is medically necessary. The Plan denied your 
request. The Plan says another scooter was received on 3/19, less than five years ago. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient?s condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 scooter. Our reviewer says that the 
requested scooter is not medically reasonable or necessary. Our physician reviewer found the documentation is 
not clear that you would be able to safely operate this vehicle in the home. The documentation does not reveal 
why your current power operated vehicle is not sufficient to perform MRADLs in the home. It is not indicated 
that the Panther22CS scooter will significantly improve ADL performance in the home. The request for the 
Panther 22CS scooter with LED lights and pneumatic tire features exceeds your medical needs.  
 
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 scooter have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Panther 22CS scooter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lightweight manual wheelchair. 
 
You asked the Plan to pre-approve these services. You say that you can no longer walk. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a manual wheelchair is covered when specific 
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 pre-approve these services. Our reviewer says that 
you do not meet the criteria for coverage. Our physician reviewer found the submitted records show that you 
have a personal mobility deficit but do not clearly indicate that the deficit impairs your participation in 
mobility-related activities of daily living (MRADLs) in the home. The records do not show that your mobility 
deficit cannot be helped by a walker or cane. There is no objective gait or neuromuscular exam. The services 
are therefore not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a lightweight manual wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the full amount for the amalgam filling (D2160), the removal of 
residual tooth roots (D7250) of tooth #12, and the unspecified preventive procedure (D1999) provided on 
August 31, 2020. 
 
You asked the Plan to pay the full amount for the dental service. You say that you do not understand how you 
have already reached your maximum allowance. You also say that you have not had that many procedures done 
this year. The Plan denied your request. The Plan says there is a maximum allowance of $1,000 each year for 
covered dental service. The Plan also says that the maximum allowance has been exhausted. 
 
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 maximum allowance of $1,000 has 
been exhausted. 
 
Date of Service Plan Paid 
5/27/2020 $163.25 
6/17/2020 $340 
7/22/2020 $340 
8/11/2020 $87.25 
8/31/2020 $67.50 
TOTAL: $1,000 
 
 
The record shows the Plan paid some towards the amalgam and the full amount for the extraction of tooth # 13. 
The maximum allowance was reached while processing this claim. Therefore, we decided that the Plan does 
not have to pay the full amount for the amalgam filling (D2160), the removal of residual tooth roots (D7250) of 
tooth #12, and the unspecified preventive procedure (D1999) provided on August 31, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on February 27, 2020. 
 
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says laboratory 
results have not been submitted for the billed date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering 
physician?s intent that the tests be performed. Based on this information, we decided that Medicare rules for 
coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to 
pay for the drug testing services provided on February 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal scaling and root planing (D4341) provided on 
March 9, 2020. 
 
You asked the Plan to pay for the dental service. You say that the sales associate told you that deep cleanings 
with this provider would be covered. You say that you confirmed this was so before you signed up for the plan. 
You say that you would not have gone to get this procedure done if you had known it would not be covered. 
You also say that you cannot afford to pay for this. The Plan denied your request. The Plan says periodontal 
scaling ad root planing is not 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 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 
periodontal scaling and root planing (D4341) provided on March 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the excision of a benign lesion (D7410) provided on August 
6, 2020. 
 
You asked the Plan to pay for the excision of a benign lesion. You say that you thought the comprehensive part 
of your insurance would cover this service. The Plan denied your request. The Plan says this service is not a 
covered benefit under your dental 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 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 
excision of a benign lesion (D7410) provided on August 6, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for drug testing provided on January 30, 2020. 
 
You asked the Plan to pay for drug tests. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says that the denial of payment for this testing is correct, because the 
documentation submitted does not include lab results for the billed date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that, except in specific circumstances, the date of 
service for laboratory testing must be the date that the specimen was collected.  
 
We looked at the file and Medicare rules. The Plan denied payment on the basis that the lab results submitted 
do not match the date of service billed. However, the lab results submitted show a collection date of January 
30, 2020 which matches the date of service billed on this claim. This drug testing does not meet any of the 
exceptions to the general date of service billing rule. Therefore, the documentation is consistent with the date of 
service billed on the claim and has been billed in accordance with Medicare rules. The Plan did not provide any 
other rationale upon which to deny payment for this testing. Based on this information, we decided that 
Medicare rules for coverage of drug tests have been met. Therefore, we decided that the Plan has to pay for 
drug testing provided on January 30, 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.