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

We decided that the Plan does not have to pay for physician's services provided on May 18, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says prior 
authorization was not obtained as required under the Plan benefits. 
 
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 
physician's services. 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 physician's services provided on May 18, 2020.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for the initial periapical x-ray. We decided that the Plan does not have to 
pay for the additional periapical x-ray.  
 
You asked the Plan to pay for the initial periapical x-ray. You say that you will not pay for the additional x-
rays. The Plan denied your request. The Plan says that 2 bitewing or periapical x-rays (D0220, D0230, D0270, 
D0272, D0273 or D0274) per calendar year. The Plan says that this limitation was met on this date of service. 
The Plan says that these x-ray codes share frequency with D0210 and D0274 which were approved on the same 
date of 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. 
 
We decided that the Plan has to pay for the initial periapical x-ray.  
 
The record shows that the Plan paid for D0210 and D0274 which were provided and paid for on the date of 
service in this case. According to the Evidence of Coverage, these 2 services do not share frequency 
limitations. As a result, the frequency limit of 2 bitewing or periapical x-rays (D0220, D0230, D0270, D0272, 
D0273 or D0274) per calendar year has not been met. Therefore, we decided that the Plan has to pay for the 
initial periapical x-ray.  
 
We also decided that the Plan does not have to pay for the additional periapical x-ray. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, once the initial periapical x-ray is 
reprocessed and paid, the frequency limit for bitewing and periapical x-rays will have been met. Therefore, we 
decided that the Plan does not have to pay for the additional periapical x-ray. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox injections. 
 
You asked the Plan to pre-approve onabotulinumtoxina (J0585). You say that the enrollee needs Botox for 
pyloric relaxation. The Plan denied your request. The Plan says Botox is not indicated to be injected into the 
pyloric muscle to increase gastric emptying. 
 
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 onabotulinumtoxina (J0585). Our 
reviewer says that the service is not reasonable or medically necessary. Our physician reviewer found though 
trials evaluating the effect of intrapyloric botulinum toxin injection on gastroparesis have been reported, there 
is no agreement whether botulinum toxin can effectively relieve the symptoms and improve the results of 
gastric emptying study in patients with gastroparesis. Available records do not provide objective 
documentation of gastroparesis by gastric emptying scan to warrant even compassionate use of botox injection 
intervention under review. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of onabotulinumtoxina (J0585) have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Botox injections.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve echocardiography services. 
 
You asked the Plan to pre-approve the echocardiography services. You say that the requested imaging services 
are medically necessary for cardiac evaluation and surveillance. The Plan denied your request. The Plan says 
there is no evidence of a detailed physical examination relevant to the imaging procedure requested. 
 
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 echocardiography services. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the enrollee has known coronary disease but normal ventricular function on 
recent nuclear stress testing in February of 2019. The enrollee has no cardiac symptoms and no murmurs or 
congestive heart failure on physical exam.  In this circumstance the records do not support the medical 
necessity for an echocardiogram and coverage criteria are not met since there are no documented covered 
indications for the procedure.  Current guidelines also do not consider echocardiography appropriate in this 
setting 
 
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 echocardiography services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve echocardiography services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an evaluation and one dental extraction to be provided 
by an oral surgeon. 
 
You asked the Plan to pre-approve the dental services. You say that this is medically necessary. The Plan 
denied your request. The Plan says services with an oral surgeon 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. The Plan covers the dental 
services when the services are provided by a participating general dentist.  
 
You are requesting services with a non-covered provider type for dental services. You are requesting an oral 
surgeon. Based on this information, we decided that the Plan's rules for coverage of the dental services have not 
been met. Therefore, we decided that the Plan does not have to pre-approve an evaluation and one dental 
extraction to be provided by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedure and two periodontal scalings and root planings provided on June 27, 2020 by an OON provider.

You asked the Plan to pay for the preventive procedure and scalings and planings. You say that the Plan's website lists this provider as in-network. You also say that you cannot afford to pay for this. The Plan denied your request. The Plan says this service was rendered by an OON provider. The Plan also says that services performed by an OON provider are not covered because your plan does not have OON benefits.

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, unspecified preventive procedure is not among those covered under this benefit. The contract also clearly states that you are responsible for 100% of the cost for services received by an OON provider. Therefore, we decided that the Plan does not have to pay for the preventive procedure and two periodontal scalings and root planings provided on June 27, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided from May 13, 2020, 
through June 3, 2020. 
 
You asked the Plan to pay for the domiciliary or rest home visit. The Plan denied your request. The Plan says 
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 Plan says that the Plan has also determined that these services are not 
urgent or emergent, nor were they approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan 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 a domiciliary or rest home visit provided from May 13, 2020, 
through June 3, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for facet joint injection services billed with CPT code 64495.

You asked the Plan to pay for the facet joint injection services. You say that the records provided support the code in dispute. The Plan denied your request. The Plan says that the code in dispute is not substantiated by the clinical documentation in the medical records.

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 CPT code 64495 is 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 coding specialist 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 facet joint injection services. Our coding specialist reviewer says that the criteria for coverage have been met. Our coding specialist reviewer found the procedure report documents, "Correct needle position was confirmed with multiple fluoroscopy views, 0.1 - 0.2 ml of radio-opaque contrast was injected at each location confirming appropriate contrast spread and non-vascular uptake. After negative aspiration 113 mg of Kenalog and 0.5 ml of 1% lidocaine was injected into the T12/L1, L1/L2 and L5/L6 facet joints. The needles were then withdrawn". The documentation supports third level injection.

We looked at this coding specialist's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the facet joint injection services have been met. Therefore, we decided that the Plan has to pay for facet joint injection services billed with CPT code 64495.

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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF admission. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 SNF admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found you received oral medications. You had 
stable vital signs. You required moderate to maximum assistance with mobility and transfers. The 
documentation does not support that you require the specialized skills, knowledge, or judgment of a skilled 
professional nurse or qualified therapist to safely and effectively provide medically necessary and reasonable 
treatment. The documentation does not support that skilled nursing or skilled therapy services are required on a 
daily basis.  
  
As a practical matter, you do not require the necessary services on an inpatient basis, at a SNF level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the inpatient hospital services, the 
emergency room visit, the ambulance transports and telehealth services provided from June 4, 2020, through 
September 2, 2020. 
 
You asked the Plan to waive the copayments for the inpatient hospital services, the emergency room visit, the 
ambulance transports and telehealth services. You say that all of these charges resulted because of your 
premature release from the hospital. The Plan denied your request. The Plan says that your cost sharing was 
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 $350 
copayment for each day for days 1 to 5 of inpatient hospital care, a $90 copayment for emergency care, a $275 
copayment for a one-way trip for each Medicare-covered Ground Ambulance service and a $20 copayment for 
telehealth services of individual sessions. 
 
You have been asked to pay a $350 copayment for the inpatient hospital services, a $90 copayment for the 
emergency room visit, a $275 copayment for each of the three ambulance transports and a $20 copayment for 
each of the three telehealth services. The inpatient hospital services fall within the days 1 to 5 of inpatient 
hospital care, the emergency room visit falls within the emergency care, the ambulance transports fall within 
the one-way trip for each Medicare-covered Ground Ambulance service and the telehealth services fall within 
 
 
the telehealth services of individual sessions 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 inpatient hospital services, the emergency room visit, the ambulance transports and telehealth services 
provided from June 4, 2020, through September 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genicular nerve block provided on March 13, 2020. 
 
You asked the Plan to pay for the services provided. You say that the procedure was medically necessary to 
manage the enrollee's pain. The Plan denied your request. The Plan says the service is considered 
investigational for the treatment of chronic knee 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 pay for the services provided. Our physician 
reviewer found that the enrollee has a history of osteoarthritis of the knees and status post left total hip 
arthroplasty.   She had increased right knee pain and received a right genicular nerve block injection. She 
reported 100% improvement from the procedure. The enrollee had complaints of continued right knee pain 
despite medical therapy and corticosteroid injections. Genicular nerve blocks and genicular nerve ablation are 
considered investigational and not medically necessary for the treatment of chronic knee pain. The review has 
determined that the genicular nerve block provided was not medically reasonable or necessary to treat the 
enrollee's condition. 
 
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 provided have not been met. Therefore, we decided that the Plan 
does not have to pay for the genicular nerve block provided on March 13, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (22853AS, 22552AS, 22551AS, 
22845ASXU) provided February 20, 2020. 
 
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the claim did not include a required 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. 
 
We find that CPT codes 22853AS, 22552AS, 22551AS, & 22845ASXU are not supported in the medical 
record. Specifically, the claim was missing a required modifier. Medicare rules require that when Assistant 
Surgeon services are billed by a Nurse Practitioner, modifier 80, 81 or 82 be used. Based on this information, 
we decided that Medicare rules for coverage of the surgical services have not been met. Therefore, we decided 
that the Plan does not have to pay for surgical services (22853AS, 22552AS, 22551AS, 22845ASXU) provided 
February 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the full amount for a complete lower denture (D5120). 
 
You asked the Plan to pre-approve the full amount for the dental item. You say that you do not have enough 
bone to make a base. You also say that you cannot eat food. The Plan denied your request. The Plan says there 
is an annual maximum of $1,000 for dental services. The Plan says that the annual maximum has been reached. 
 
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 annual maximum of $1,000 was 
reached while processing this request. The record shows that the Plan approved $880 towards the $904 allowed 
for the denture. The record shows that the Plan previously paid $120 for services that you received on October 
6, 2020. Therefore, we decided that the Plan does not have to pre-approve the full amount for a complete lower 
denture (D5120).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa (J7323). 
 
You asked the Plan to pre-approve Euflexxa. The Plan denied your request. The Plan says The Plan says that 
the information submitted does not meet the Plan's medical necessity guidelines for coverage. 
 
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 Euflexxa. Our reviewer says that 
Euflexxa is not medically reasonable and necessary for the enrollee. Our physician reviewer found the Plan's 
coverage criteria requires a trial of Monovisc and Orthovisc before they will approve the requested drug. There 
is insufficient documentation that the enrollee meets the Plan's step therapy criteria. Our reviewer found that 
additionally, there is insufficient documentation that the Plan's preferred drugs are not medically appropriate 
for this enrollee.  
 
 
Our physician reviewer also found that in summary, neither step therapy or step therapy exception criteria are 
met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa (J7323).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dermatology services (88321) provided on November 3, 
2019, by an out-of-network provider. 
 
You asked the Plan to pay for the dermatology services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the services were not emergent and there were network providers 
available to provide this service. 
 
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 service 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 dermatology services (88321) provided on November 3, 2019, by an out-of-
network provider.