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

We decided that the Plan does not have to pre-approve Zilretta. You asked the Plan to pre-approve these services. You say that the injections help your pain. The Plan denied your request. The Plan says the services are not medically necessary. The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that you have osteoarthritis of the left knee. You had a Zilretta injection to the left knee on February 24, 2020. A repeat Zilretta injection is not considered safe and effective. 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 Zilretta.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodic oral exam (D0120), preventive cleaning (D1110) and panoramic x-ray (D0330) provided on December 4, 2019.
You asked the Plan to pay for the dental services. You say that you thought you were enrolled in the enhanced supplemental benefit package powered by the Dental PPO. The Plan denied your request. The Plan says you elected to purchase the embedded basic dental plan which is included in the medical plan with Medicare.
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. The Plan paid for the oral exam and you are responsible for the cost-share of the preventive cleaning. Panoramic x-rays are not listed in your EOC as a covered benefit under your medical benefit. Therefore, we decided that the Plan does not have to pay for periodic oral exam (D0120), preventive cleaning (D1110) and panoramic x-ray (D0330) provided on December 4, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve core build up, including pins when required (D2950) and crowns
(D2751) for teeth # 4, 14, and 21.
You asked the Plan to pre-approve the dental services. You say that you have temporary fillings. You say that
you need crowns done. You also say that no other dentist is going to want to finish treatment that was already
started. The Plan denied your request. The Plan says that the requested dental services are not covered. The
Plan says that the dental services with the Dental PPO terminated as of December 31, 2019.
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.
We looked at the case file and the Medicare rules. Based on this information, we decided that the Plan's rules
for coverage of the dental services have been met. Therefore, we decided that the Plan has to pre-approve core
build up, including pins when required (D2950) and crowns (D2751) for teeth # 4, 14, and 21.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup, including any pins when required, and porcelain crown provided on September 10, 2019.
You asked the Plan to pay for the core buildup and crown. You say that you were told that this provider was participating with your plan. You also say that you were unaware that this provider was non-participating with your plan. The Plan denied your request. The Plan says their records do not show that your dentist is in the Dental PPO network.
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 covered when they are received out-of-network. Therefore, we decided that the Plan does not have to pay for the core buildup, including any pins when required, and porcelain crown provided on September 10, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the difference for the actual porcelain, 3 surface, onlay (D2643)
and billed 3 surface metallic onlay (D2543) for tooth # 15 provided on December 10, 2019.
You asked the Plan to pay the difference for the dental service you received versus the dental service that you
were billed. You say that the Plan only pays for the use of noble metals (not including gold) for use in crowns
and onlays when they are molars. You say that you have issues with heavy metals which cause problems with
your immune system. You also say that the claim amount should be reduced since you are not able to have a
noble metal crown or onlay. The Plan denied your request. The Plan says crowns containing porcelain or resin
on posterior teeth are not benefits of the dental plan. The Plan also says that the allowance that was made was
established under the optional service provision in 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 porcelain onlay that you actually
received is not among those covered under this benefit. However, the record shows the Plan applied the
optional service provision and paid 50% of the allowed amount. Therefore, we decided that the Plan does not
have to pay the difference for the actual porcelain, 3 surface, onlay (D2643) and billed 3 surface metallic onlay
(D2543) for tooth # 15 provided on December 10, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, first intraoral periapical x-ray,
two additional intraoral periapical x-rays, bitewings, and periodontal maintenance provided by an OON
provider, on November 26, 2019.
You asked the Plan to pay for the periodic oral evaluation, intraoral periapical x-rays, bitewings, and
periodontal maintenance. You say that you have been going to this provider for over 20 years. You also say
that you thought by opting to choose to pay an additional fee on the Advantage Plan, you would continue to be
able to have some dental coverage. The Plan denied your request. The Plan says this dentist is not a
participating provider with your 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
covered when they are received out-of-network. Therefore, we decided that the Plan does not have to pay for
the periodic oral evaluation, first intraoral periapical x-ray, two additional intraoral periapical x-rays, bitewings,
and periodontal maintenance provided by an OON provider, on November 26, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Diclofenac sodium 1% gel for the enrollee.
You asked the Plan to pre-approve the gel. You say that this is medically necessary. The Plan denied your
request. The Plan says Medicare says Part B programs can only provide limited benefits for prescription drugs.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Diclofenac sodium 1% gel
for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on December 16, 2019 by
an out of network (OON) provider.
You asked the Plan to pay for skilled nursing services. You say that you would like this claim reprocessed and
approved for payment. The Plan denied your request. The Plan says no prior authorization was 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 skilled nursing services provided on December 16,
2019 by an out of network (OON) provider.
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 a complex rehab team is not needed to take care of the enrollee.
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 enrollee does not require the intensity of services provided at an IRF. Specifically,
the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician
evaluation. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR).
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chronic care management services provided to the enrollee
on December 11, 2019.
You asked the Plan to pay for the services. You say that the services were rendered in good faith. The Plan
denied your request. The Plan says there is no network deficiency for these services, and alternate network
providers were found.
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 chronic care management services provided to the
enrollee on December 11, 2019.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve nasal/sinus endoscopy, surgical with ethmoidectomy and
maxillary antrostomy for the enrollee.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your
request. The Plan says that the received records did not show 12 continuous weeks of nasal congestion, mucus
and pus nasal drainage, facial pain, facial pressure, or loss of smell.
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 the surgery. Our reviewer says that the
requested services are considered medically reasonable and necessary in this case. Our physician reviewer
found the ENT note states that the patient suffers from chronic recurrent sinusitis. Typically with recurrent
sinusitis, the patient will suffer from sinus issues during the time of the infection, and then his/her symptoms
will partially or fully resolve between infections. The benefit of doing surgery for these patients is to avoid
using multiple rounds of antibiotics, which can eventually lead to untoward side effects or even antibiotic
resistance. It would be expected that a CT sinus done between infections will be mostly clear. However, the
patient clearly had inadequate sinus surgery previously and therefore continues to suffer from recurrent sinus
infections. A patient with recurrent sinusitis will not have 12 weeks of constant symptoms, but can still benefit
from surgical management.
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 surgery have been met. Therefore, we decided that the Plan has to preapprove
nasal/sinus endoscopy, surgical with ethmoidectomy and maxillary antrostomy 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an outpatient hospital services for a colonoscopy provided on
December 6, 2019.
You asked the Plan to pay for the outpatient hospital services. The Plan denied your request. The Plan says
non-emergent, non-urgent services with out-of-network providers require prior authorization.
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
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 an outpatient hospital services for a colonoscopy provided on
December 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit coded 99215 provided on October 30, 2019.
You asked the Plan to pay for the office visit. 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 separately payable.
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 99215 is office or other outpatient visit for the evaluation
and management of an established patient, which requires at least 2 of these 3 key components: A
comprehensive history; A comprehensive examination; Medical decision making of high complexity.
Counseling and/or coordination of care with other physicians, other qualified health care professionals, or
agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.
Usually, the presenting problem(s) are of moderate to high severity. Typically, 40 minutes are spent face-toface
with the patient and/or family.
We find that CPT code 99215 is not supported in the medical record. Specifically, another service was billed
for this date of service by a provider with the same specialty. Physicians in the same group practice who are in
the same specialty must bill and be paid as though they were a single physician. If more than one evaluation
and management (face-to-face) service is provided on the same day to the same patient by the same physician
or more than one physician in the same specialty in the same group, only one evaluation and management
service may be reported unless the evaluation and management services are for unrelated problems.
Based on this information, we decided that Medicare rules for coverage of the office visit have not been met.
Therefore, we decided that the Plan does not have to pay for the office visit coded 99215 provided on October
30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the hearing aids (V5243) provided by the
out of network provider on October 29, 2019.
You asked the Plan to issue reimbursement for the hearing aids. You say that you are requesting a
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the hearing aids
were provided by an out of network provider. Therefore, the hearing aids are not covered under your
contractual policy.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case.
We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage of the hearing aids have not been met. Specifically, the hearing aids were not purchased from the innetwork
provider as required in the Plan contract. Therefore, we decided that the Plan does not have to issue
reimbursement for the hearing aids (V5243) provided by the out of network provider on October 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on November 12,
2019.
You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the charges
and feel that the plan should not have paid them. 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 $25
copayment for each specialist visit.
You have been asked to pay a $25 copayment for a specialist visit. A specialist visit falls within the
physician/practitioner services, including doctor's office visits benefit category. This means that you have been
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have
to waive the copayment for a specialist visit provided on November 12, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Invokana (J8499).
You asked the Plan to pre-approve the Invokana. You say that you would like reconsideration because this drug
is medically necessary. The Plan denied your request. The Plan says this drug is not covered for the member's
condition under Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Invokana (J8499).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram services coded 93010 provided on
December 29, 2019.
You asked the Plan to pay for the electrocardiogram services. 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.
In this case, the CPT Code Manual definition of code 93010 is electrocardiogram, routine ECG with at least 12
leads; interpretation and report only.
We find that CPT code 93010 is not supported in the medical record. Specifically, this code is bundled with
emergency room visit (code 99285) that was billed on the same date of service by the same group but a
different rendering provider. The documentation supports an electrocardiogram was performed, but does not
include the interpretation and report. Based on this information, we decided that Medicare rules for coverage of
the electrocardiogram services have not been met. Therefore, we decided that the Plan does not have to pay for
the electrocardiogram services coded 93010 provided on December 29, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for comprehensive eye examination (92014)
outpatient office visit (99212) diagnostic imaging of retina (92134) diagnostic imaging of optic nerve of eye
(92133) and visual field test (92083) provided November 11, 2019 to January 15, 2020.
You asked the Plan to waive the copayment for the vision services. You say that the services rendered were a
part of your annual routine eye exam. The Plan denied your request. The Plan says the claims for the services
rendered were processed correctly and the correct cost share 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 $35
copay for each Medicare covered exam to treat an eye condition and $85 copay for each covered diagnostic
procedure or test at a network doctor's office.
You have been asked to pay $176 for the diagnostic vision services. The diagnostic vision services fall within
the Outpatient diagnostic tests and therapeutic services and supplies and 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 examination (92014) outpatient office
visit (99212) diagnostic imaging of retina (92134) diagnostic imaging of optic nerve of eye (92133) and visual
field test (92083) provided November 11, 2019 to January 15, 2020.