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

We decided that the Plan does not have to pay for the detailed and extensive oral evaluation (D0160) or pay in 
full for the deep sedation/general anesthesia (D9222) provided on June 17, 2021, and June 23, 2021. 
 
You asked the Plan to pay for the detailed and extensive oral evaluation and deep sedation/general anesthesia. 
You say that you do not agree with the determination that the anesthesia has not been reimbursed because you 
have atrial fibrillation and need to be on anticoagulants in the non-maxillofacial area. The Plan denied your 
request. The Plan says these services are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the detailed and extensive oral 
evaluation (D0160) is not among those covered under this benefit. The record shows that the rate paid by the 
Plan for the deep sedation/general anesthesia was the rate established by the Plan, and not the $250 that was 
charged by the provider. Therefore, we decided that the Plan does not have to pay for the detailed and extensive 
oral evaluation (D0160) or pay in full for the deep sedation/general anesthesia (D9222) provided on June 17, 
2021, and June 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an X-Ray examination (71045) provided on May 20, 2021. 
 
You asked the Plan to pay for X-Ray 71045. You say that this claim was denied in error. The Plan denied your 
request. The Plan says the denial of payment for this service is correct, because code 71045 has a procedure-to-
procedure (PTP) edit of 1 with code 32555 meaning that this code is not separately payable without an 
appropriate 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. In this case, we have confirmed that code X-Ray 
71045 is a column II code to column I code 32555. 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 an X-Ray examination (71045) provided on May 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services coded 71046 provided on June 1, 2021. 
 
You asked the Plan to pay for the x-ray 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 71046 is radiologic examination, chest; 2 views. 
 
We find that CPT code 71046 is not supported in the medical record. Specifically, the documentation does not 
support two views of chest x-ray were performed on this date of service in question. Based on this information, 
we decided that Medicare rules for coverage of the x-ray services have not been met. Therefore, we decided 
that the Plan does not have to pay for the x-ray services coded 71046 provided on June 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an outpatient hospital visit, and office visit provided on May 
12, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient hospital visit and office visit. You say that you did not have an 
office visit on this date of service. 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 did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
medical record shows you were seen in order to establish care. Therefore, we decided that the Plan does not 
have to pay for the outpatient hospital visit, and office visit provided on May 12, 2021, by an out-of-network 
(OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair for the enrollee. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is no medical need for the multiple power options included with a group 3 
power wheelchair. 
 
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 wheelchair. Our reviewer says that 
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found the enrollee 
does not use a ventilator mounted to the wheelchair, and does not meet the coverage criteria for a power tilt and 
power recline seating system. There is no evidence of intermittent catheterization, spasticity, or evidence of 
being high risk for a pressure ulcer therefore the requested Group 3 power wheelchair with multiple power 
options exceeds the enrollee's medical need and is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 3 power wheelchair for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that this request is medically reasonable 
and necessary. The Plan denied your request. The Plan says the requested procedure is not 
experimental/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 Vertiflex procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee indicates that the enrollee has chronic low back pain and lumbar spinal 
stenosis with neurogenic claudication. The record indicates that imaging shows that the enrollee has multilevel 
disease including moderate to severe central stenosis and the levels requested for treatment. The record does 
not indicate that the enrollee is not indicated for operative treatment at more than two levels. The elements of 
the coverage criteria are not satisfied. 
 
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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit provided on June 22, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the home visit. You say that no referral could be provided because the enrollee 
had not been seen for a long time. 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 did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the home visit provided on June 22, 2021, by an out-of-network 
(OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2300, 
E2311, E2313, E2377, K0108) for the enrollee. 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says this 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 accessories. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the power seat elevation feature (E2300) and the K0108 cell phone/media device holder are not 
medically necessary. The E2300 and the K0108 are not primarily medical in nature therefore these items are 
not medically necessary. In terms of E2311, E2313, and E2377, the documentation does not reveal that the 
enrollee requires other types of proportional input devices (e.g., mini-proportional or compact joysticks, 
touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, 
etc.). The enrollee does not need to operate 3 or more powered seating actuators through the drive control, a 
separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative 
speech device or computer through the chair's drive control), or an attendant control. The enrollee's strength 
and function in the upper extremities supports that the enrollee can control any power options through their 
own individual switches. 
 
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 accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional power wheelchair accessories (E2300, E2311, E2313, E2377, K0108) for the 
enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on January 6, 
2021 by a Medicare opt out provider. 
 
You asked the Plan to pay for the periodontal maintenance. You say that you were not advised by the dentist or 
the facility that the provider had opted out of Medicare. You also say that they should have known to inform 
you because you are on a Medicare plan. The Plan denied your request. The Plan says this service was rendered 
by a provider who chose not to receive Medicare funds. The Plan also says that the treating provider opted out 
of Medicare effective September 22, 2015, to September 22, 2023. 
 
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 by a provider who has opted out of Medicare. Therefore, we decided that the 
Plan does not have to pay for the periodontal maintenance (D4910) provided on January 6, 2021 by a Medicare 
opt out provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) provided on September 16, 2020, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that these services were medically necessary. The Plan 
denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON 
provider. 
 
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 the office visit (99214) provided on September 16, 
2020, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on December 
31, 2019. 
 
You asked the Plan to pay for the CT scan. You say that the enrollee had multiple exams on this date of 
service. The Plan denied your request. The Plan says the claim processed correctly. 
 
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 74160 is Computed tomography, abdomen; with contrast 
material(s). We find that CPT code 74160 was billed with CPT code 74177. Code 74160 may be eligible for 
payment if an appropriate modifier is appended. The claim provided does not include a modifier suitable for 
payment. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been 
met. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan 
provided on December 31, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuation of skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve a continuation of SNF care. You say that you had the coronavirus, and your 
body is having to readjust due to the new injury to your body. You say that you have not progressed and have 
had a set back with your physical therapy and pain levels. You say that you need more time to transition back 
home alone without further health issues, accidents or injuries. The Plan denied your request. The Plan says the 
enrollee does not meet the requirements for coverage of a continuation of SNF care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 a continuation of SNF care. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received 
oral medications, physical therapy and occupational therapy in the SNF. By the dates in question, the enrollee 
was at a modified independent to supervision level for functional mobility, including gait to 50 feet. The 
enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service 
needs. There are no identifiable skilled therapy service needs. The enrollee does not meet the severity of illness 
or intensity of service criteria for an inpatient basis in a SNF 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 a continuation of SNF care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a continuation of skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for wound care supplies provided on April 9, 2021. 
 
You asked the Plan to pay for wound care supplies. You say that the requested items are a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order, proof of delivery, or relevant medical records which 
support medical necessity for the supplies provided in this case. The record shows that the Plan made several 
attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not 
have to pay for wound care supplies provided on April 9, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory work provided on June 28, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the laboratory work. You say that the service is medically necessary. 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 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. The 
record shows CPT code 36415 was billed which means the provider had the opportunity to confirm insurance 
coverage and authorization. Therefore, we decided that the Plan does not have to pay for the laboratory work 
provided on June 28, 2021, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. You say that the physical therapy notes provided show the 
need for continued therapies in order for the enrollee to be able to reach his maximum abilities for daily living 
activities. You say that the enrollee has the potential to reach a higher level of participating with his activities 
of daily living to maximize his abilities to have a functional life. The Plan denied your request. The Plan says 
the notes do not show that the enrollee needs to go to a SNF. The Plan says that the enrollee's ongoing care 
needs can be provided at a lower level. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 the SNF services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral 
medications, had stable vital signs, and was alert with confusion. The enrollee received physical therapy and 
occupational therapy. By the dates in question, the enrollee was at a contact guard to minimal assist level for 
functional mobility, including gait to 60 feet x2. The enrollee required varying assist with activities of daily 
living. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service 
needs. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a 
SNF 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 SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on May 5, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the service was medically necessary. 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 did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the office visit provided on May 5, 2021, by an out-of-network 
(OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on June 22, 2021 by an out-of-
network (OON) provider. 
 
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 rendered are not a covered benefit. 
 
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 the office visit provided on June 22, 2021 by an 
out-of-network (OON) provider.