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

 
We decided that the Plan does not have to pre-approve the maxillary partial denture, cast metal framework with 
resin denture bases (including any retentive/clasping materials, rets and teeth) (CPT code D5213). 
 
You asked the Plan to pre-approve the dental services. You say that your partial anterior denture broke, and 
your new dentist recommended a new one in order to be able to chew because if not, you cannot eat. The Plan 
denied your request. The Plan says you exhausted your benefit frequency limit. 
 
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. 
 
Review of the file shows that you were provided with the maxillary partial denture (CPT code D5213) on June 
6, 2019. Your 2022 EOC states, complete dentures (upper and lower) (one (1) upper complete and 1 lower 
complete denture every five (5) years, including routine post-delivery care) or partial dentures (upper and 
lower) (1 upper and/or 1 lower partial denture every 5 years, including routine post-delivery care) Includes necessary extractions to fit dentures (unlimited). Therefore, we decided that the Plan does not have to pre-
approve the maxillary partial denture, cast metal framework with resin denture bases (including any 
retentive/clasping materials, rets and teeth) (CPT code D5213).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis 5MG tablet. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says Eliquis is a patient self-administered drug and not covered under the enrollee's Part 
B benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered 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 Eliquis 5MG tablet.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gocorvi 137 (J8499). 
 
You asked the Plan to pre-approve Gocorvi 137. You say that the enrollee needs this medication. 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 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 Gocorvi 137 (J8499).  
 
Benefits for Gocorvi 137 may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the laboratory services (CPT code(s): 85025, 80053, 
36415) to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the doctor orders metabolic test 
every two (2) weeks to make sure your chemotherapy is working. You state the doctor can obtain the results 
through the hospital. The Plan denied your request. The Plan says there is not a gap issue and there are in 
network providers available who can supply the requested 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the laboratory services (CPT code(s): 85025, 80053, 36415) to be provided by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prochlorperazine maleate 10 mg tablet. 
 
You asked the Plan to pre-approve Prochlorperazine maleate. You say that the requested drug is medically 
necessary. 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 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 Prochlorperazine maleate 
10 mg tablet.   
Benefits for Prochlorperazine maleate may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic exercise services (97110) provided on 
September 13, 2021.  
You asked the Plan to pay for therapeutic exercises. You say that these services were necessary and were billed 
appropriately. The Plan denied your request. The Plan says this service is not supported in the record. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 97110 is not supported in the medical record. Specifically, the documentation shows 
that this claim was billed by a Nurse Practitioner but the therapy services at issue were rendered by a Physical 
Therapist. There is no indication that the Nurse Practitioner was present on site while the therapy services were 
being rendered. The incident-to requirements have not been met in this case. Therefore, we decided that the 
Plan does not have to pay for the therapeutic exercise services (97110) provided on September 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (CPT code 99204) provided on July 2, 2021. 
 
You asked the Plan to pay for the office visit. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. NCCI PTP edit exists between 99204 and 77263, 77470 and 77334. This PTP edit has a modifier indicator of 1, modifiers associated with NCCI are 
allowed, however, an appropriate NCCI modifier was not billed with this PTP code edit. Based on the claim 
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for the office visit (CPT code 99204) provided on July 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 28, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on May 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyeglasses provided on October 20, 2021. 
 
You asked the Plan to pay for eyeglasses. You say that you needed to have your eyeglasses changed because of 
surgery and you needed stronger eyeglasses. The Plan denied your request. The Plan says you have exceeded 
limits set in the subscriber agreement. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan 
covers these services every 2 years. 
 We looked at the file and the Plan's rules. The file shows that you received the eyewear benefit for eyeglasses 
provided on February 10, 2021. Based on this information, we decided that the Plan's rules for coverage of 
eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglasses provided 
on October 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT 
code 22869). 
 
You asked the Plan to pre-approve the surgery. You say that you highly recommend this minimally invasive 
procedure when conservative treatments have failed and a safer alternative to a laminectomy or spinal fusion. 
The Plan denied your request. The Plan says it has not been shown to be safe and effective in long term studies 
and there is a lack of evidence to support that interspinous spacer devices are as safe and effective as the gold 
standard of decompression. 
 
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 surgery. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertiflex device is experimental. More research is needed. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital care and transcatheter aortic valve 
replacement (TAVR/TAVI) with prosthetic valve; percutaneous femoral artery approach (CPT code 33361). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says they require notes that show the enrollee has an approved heart condition for this procedure (symptomatic severe aortic valve stenosis). The Plan states the enrollee's doctor's notes do not show 
this; therefore, this heart procedure is not medically necessary. 
 
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 items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the most recent echocardiogram showed aortic stenosis, with valve area over 1.1 sq cm. This 
degree of aortic stenosis would not be considered severe in this enrollee. As a result, at this time the requested 
TAVR would not be considered medically necessary in this enrollee's clinical management based on the 
submitted documentation. 
 
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 inpatient hospital care and transcatheter aortic valve replacement (TAVR/TAVI) with 
prosthetic valve; percutaneous femoral artery approach (CPT code 33361).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-ray services provided to the enrollee on June 18, 2021. 
 
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 the provider did not bill as required by Medicare coding regulations. 
 
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, we have confirmed that code 71045 is a column II code to column I code 71046. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for x-ray services provided to the enrollee on June 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 13, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that laboratories shall not report multiple individual CPT 
codes describing the component test results. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have 
to pay for the laboratory services provided on October 13, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray exam of an ankle (73610) provided on October 1, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an x-ray exam of an ankle. You say that the ordering physician's office failed to 
obtain a referral for the denied service. The Plan denied your request. The Plan says the rendering provider is 
non-participating and there is not a referring provider. The Plan also says that there is no evidence that this is 
urgent or emergent, nor were the services 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 had network providers 
available who could have provided 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 an x-ray exam of an ankle (73610) provided on 
October 1, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for targeted genomic sequence analysis panel (CPT code 0242U) 
provided on September 7, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. CPT Code 0242U 
remains not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the 
patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was 
obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates 
that the specimen was obtained in an office setting POS 11. Also, the laboratory results submitted indicate the 
specimen was collected on August 31, 2021, and received by the lab on September 2, 2021. Of note, the patient 
resides in Pennsylvania (PA) and the billing laboratory is located in California (CA); therefore, the billed code 
cannot be verified. It is noted multiple attempts were made to obtain additional information from the provider. 
Therefore, we decided that the Plan does not have to pay for targeted genomic sequence analysis panel (CPT 
code 0242U) provided on September 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a flex walk system for a prosthesis. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a flex walk system is covered when 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the documentation is not consistent that 
the enrollee is a K3 ambulator and requires the flex walk system. The treatment medical provider 
documentation does not reveal that the enrollee's activities require a K3 foot. The evaluation notes that his 
environmental barriers are reduced stamina and endurance. The evaluation dated January 13, 2022 states he 
walked regularly in his home but rarely walked outdoors 12 months prior to amputation. The flex walk system 
is 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 flex walk system for a prosthesis.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a comprehensive metabolic panel (80053) 
provided on July 21, 2021. 
 
You asked the Plan to waive the copayment for the comprehensive metabolic panel. You say that the services 
should be covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the 
services provided. 
 
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 $10 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
 
 
 
 You have been asked to pay a $6.62 copayment for a comprehensive metabolic panel, which is less than the 
$10 stated in the Plans contract. Comprehensive metabolic panels fall 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 a 
comprehensive metabolic panel (80053) provided on July 21, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy services provided from 
October 4, 2021, to October 25, 2021. 
 
You asked the Plan to waive the copayment for the physical therapy services. You say that the services should 
be covered and you received a bill that you did not agree with. The Plan denied your request. The Plan says the 
cost-sharing applied correctly based on the services provided. 
 
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 $40 
copayment for Outpatient rehabilitation services.  
 
 
 
 
 
 You have been asked to pay a $160 copayment for four physical therapy visits. Physical therapy services fall 
within the Outpatient rehabilitation 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 physical therapy services provided from October 4, 2021, to October 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on October 6, 
2021. 
 
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 the provider did not bill as required by Medicare coding regulations. 
 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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for imaging services provided to the enrollee on October 6, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lexapro 10 mg tablet. 
 
You asked the Plan to pre-approve Lexapro. You say that the requested drug is medically necessary. 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 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 Lexapro 10 mg tablet.  
 
Benefits for Lexapro may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.