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

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT). 
 
You asked the Plan to pre-approve PBRT. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been 
met. 
 
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 PBRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found routine use of proton therapy for breast cancer is not an accepted standard of care. Intensity 
modulated radiation therapy (IMRT) that is photon based is designed to facilitate normal tissue sparing and 
could very readily be considered in this enrollee if a 3D plan is not acceptable. While proton therapy can be 
used (and is often used for select patients with unique anatomic considerations) the case file does not provide a 
plausible rationale for the need of proton therapy over conventional radiation and/or IMRT in this enrollee. 
Thus, proton therapy would not be furnished in accordance with accepted standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of PBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve proton beam radiation therapy (PBRT).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a podiatry visit provided on April 13, 2022. 
 
You asked the Plan to pay for a podiatry visit. You say that the patient presented the wrong insurance card, and 
we were unaware we needed to get a prior authorization. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s).there was no preauthorization by a primary care provider (this is different than a 
referral) for an out-of-network (OON) provider or facility, and this was not an emergency. Therefore, the 
decision is upheld. Therefore, we decided that the Plan does not have to pay for a podiatry visit provided on 
April 13, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for a Pembrolizumab injection and administration provided to the enrollee 
on December 23, 2021. 
 
You asked the Plan to pay for the injection. You say that this should be paid for. The Plan denied your request. 
The Plan says that experimental or investigational services are not covered. 
 
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 pay for the injection. Our reviewer says that the 
services at issue in this case were medically reasonable and necessary. Our physician reviewer found 
Lenvatinib plus pembrolizumab showed promising antitumor activity in patients with advanced endometrial 
carcinoma who have experienced disease progression after prior systemic therapy, regardless of tumor MSI 
status. The combination therapy had a manageable toxicity profile. Thus, this should be approved, as 
microsatellite stable is not needed to approve. 
 
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 injection have been met. Therefore, we decided that the Plan has to pay for a 
Pembrolizumab injection and administration provided to the enrollee on December 23, 2021.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of a new implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve placement of a new ILR. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that cardiac event monitors are covered when specific 
criteria are met.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve placement of a new ILR. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found you have a history of atrial 
fibrillation. There is no documentation provided to suggest a history of unexplained syncope, cryptogenic 
stroke or any other apparent indication for an ILR. In summary, there is insufficient documentation to support 
the medical necessity for insertion of an ILR in your clinical 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 placement of a new ILR have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of a new implantable loop recorder (ILR).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4314 and A4357 billed for date of service 
April 15, 2022. 
 
You asked the Plan to pay for procedure code A4314 and A4357. You say that this should be paid for. The Plan 
denied your request. The Plan says procedure code A4314 and A4357 is considered bundled and 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 procedure code. 
 
We find that procedure codes A4314 and A4357 has a status indicator of P on the Physician Fee Schedule. This 
means that procedure code A4314 and A4357 is not separately payable. Based on this information, we decided 
that Medicare rules for coverage of procedure code A4314 and A4357 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code A4314 and A4357 billed for date of service April 
15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested Intracept intraosseous 
basivertebral nerve ablation at L5-S1, in this case, is not medically reasonable or 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 an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup (D2954), a pontic (D6241), and a crown 
(D6751) for tooth #11, #12, #13, and #14 provided on July 18, 2022, and August 4, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to cover the denied 
dental services. The Plan denied your request. The Plan says the denial of payment for these services is correct, 
because the core buildup, pontics, and crowns are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for core 
buildup (D2954), a pontic (D6241), and a crown (D6751) for tooth #11, #12, #13, and #14 provided on July 18, 
2022, and August 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for cardiology visits provided on July 21, 
2022, to July 31, 2022. 
 
You asked the Plan to waive the copayment for cardiology visits. You say that there should not be so 
copayments for these providers. The Plan denied your request. The Plan says this cost sharing was charged 
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 $45 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $45 copayment for cardiology visits. This item/service falls within the 
physician/practitioner services, including doctors 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.A $45 copayment x 3 visits = a $135 total. 
Therefore, we decided that the Plan does not have to waive the copayment for cardiology visits provided on 
July 21, 2022, to July 31, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit on July 14, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you are requesting reconsideration. 
The Plan denied your request. The Plan says this cost sharing was charged 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 $20 
copayment per visit for a specialist office visit. Covered services include medically necessary medical care or 
surgery services furnished in a physicians office, certified ambulatory surgical center, hospital outpatient 
department, or any other location. Consultation, diagnosis, and treatment by a specialist.  
 
 
 You have been asked to pay a $20 copayment for office visit. This item/service falls within the 
Physician/practitioner services, including doctor's office visit 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 office visit on July 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a magnetic resonance imaging (MRI) of the thoracic spine 
without contrast provided on June 29, 2022. 
 
You asked the Plan to pay for the MRI. You say that you have severe spine pain, and the MRI was ordered to 
check the condition of your spine. The Plan denied your request. The Plan says the denial of payment for the 
MRI is correct, because there was a lack of medical notes to explain why the test is medically needed. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the MRI. Our reviewer says that the MRI of 
the thoracic spine is not medically necessary. Our physician reviewer found that review of the records showed 
reports of MRI of the cervical and thoracic spine with a history of spinal stenosis. There are no other medical 
records supporting the need or medical necessity of the exam done on June 29, 2022. The enrollee sent a letter 
of appeal dated August 28, 2022, and that letter detailed multiple items that had they been included in the 
medical records would likely have provided ample evidence of the medical necessity of the performed MRI of 
the thoracic spine. However, absent any relevant clinical information from the requesting the physician the scan 
remains denied per rules of coverage by the plan. 
 
  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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pay for a magnetic resonance imaging (MRI) of the thoracic spine without contrast provided on June 29, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service July 13, 
2022. 
 
You asked the Plan to pay for procedure code 71045. The Plan denied your request. The Plan says payment for 
code 71045 is bundled into payment for code 74022. 
 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 74022. 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 procedure code 71045 billed for date of service July 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for oxygen concentrator provided on July 19, 
2022. 
 
You asked the Plan to waive the coinsurance for oxygen concentrator. You say that you want to lower the cost. 
The Plan denied your request. The Plan says this cost sharing was charged 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 20% 
coinsurance for durable medical equipment and related supplies. The allowed amount of oxygen concentrator 
total $108.55, resulting in a coinsurance amount of $21.71. 
 
You have been asked to pay 20% coinsurance for oxygen concentrator. This item/service falls within the 
durable medical equipment and related 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 
coinsurance for oxygen concentrator provided on July 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided by a 
participating provider on August 24, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not informed properly about how 
often you would be covered. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service July 15, 2022. Therefore, 
we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided by a 
participating provider on August 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient specialist visit provided on 
June 24, 2022. 
 
You asked the Plan to waive the copayment for an outpatient specialist visit. You say that you already paid a 
copay and shouldnt owe anything for the facility. The Plan denied your request. The Plan says this cost 
sharing was charged 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 $200 
copayment for outpatient hospital services. 
 
You have been asked to pay a $200 copayment for an outpatient specialist visit. This item/service falls within 
the outpatient hospital 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.You have been asked to pay the allowed amount of $138 which is less than the 
$200 copayment for an outpatient specialist visit. Therefore, we decided that the Plan does not have to waive 
the copayment for an outpatient specialist visit provided on June 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 24, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says you billed with an incorrect place of 
service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on January 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 25, 2022. 
 
You asked the Plan to pay for an office visit. You say that this was covered every other time you saw this 
provider. They were not out of network before. The Plan denied your request. The Plan says that unauthorized, 
out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s).there was no preauthorization by a primary care provider (this is different than a 
referral) for an out-of-network (OON) provider or facility, and this was not an emergency. Therefore, we 
decided that the Plan does not have to pay for an office visit provided on July 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup (D2950) for tooth number 14 and a porcelain 
crown (D2750) for tooth number 14 provided on August 31, 2022. 
 
You asked the Plan to pay for core buildup (D2950) for tooth number 14 and a porcelain crown (D2750) for 
tooth number 14. You say that this was an emergency repair that involved removing part of the old crown and 
replacing it with a new crown. The Plan denied your request. The Plan says there is no coverage for core 
buildup (D2950). The Plan also says that they cover one porcelain crown (D2750) procedural code per calendar 
year. The Plan also says that you already received a porcelain crown (D2750) on March 25, 2022. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, core buildup (D2950) is not among 
those covered under this benefit, and certain limitations also apply for other services. The record shows a 
porcelain crown (D2750) was exhausted on date of service March 25, 2022. Therefore, we decided that the 
Plan does not have to pay for core buildup (D2950) for tooth number 14 and a porcelain crown (D2750) for 
tooth number 14 provided on August 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodic oral evaluation - established patient (D0120), 
bitewings - four radiographic images (D0274) and prophylaxis-adult (D1110) provided on August 8, 2022. 
 
You asked the Plan to pay for dental services. You say that you do not have supplemental dental insurance, but 
you were told the services requested are imbedded benefits and would be covered. The Plan denied your 
request. The Plan says this service is not covered under your Plan. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for periodic oral evaluation - 
established patient (D0120), bitewings - four radiographic images (D0274) and prophylaxis-adult (D1110) 
provided on August 8, 2022.