Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient services provided by an out-of-network 
provider on June 10, 2021. 
 
  You asked the Plan to pay for the outpatient services. You say that the services were medically necessary and 
equal with treatment standards for the patient. You say that they found that no authorization was required and 
the services should be reimbursed. The Plan denied your request. The Plan says the services provided require 
prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
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 outpatient services provided by an out-of-
network provider on June 10, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve ondansetron tablets. 
 
You asked the Plan to pre-approve ondansetron. You say that the enrollee's conditions benefit from 
ondansetron. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, 
because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare 
Part D prescription drug 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 because they are not being used as a full therapeutic replacement for intravenous anti-emetics 
during a chemotherapy regimen. Therefore, we decided that the Plan does not have to pre-approve ondansetron 
tablets.  
 
Benefits for ondansetron 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anterior instrumentation (22845) provided on April 9, 2021. 
 
You asked the Plan to pay for anterior instrumentation. You say that this claim was not processed correctly. 
The Plan denied your request. The Plan says the denial of payment for this code is correct, because the record 
does not support this code. 
 
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 22845 is anterior instrumentation; 2 to 3 vertebral 
segments (list separately in addition to code for primary procedure). 
 
We asked our coder 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 anterior instrumentation. Our reviewer says that this code does not meet the criteria for payment. Our reviewer found code 22845 is inclusive to code 22853. The 
operative report does not document a separate plate that spans the interspace, to provide independent 
stabilization, and would be included with code 22853. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of anterior instrumentation have not been met. Therefore, we decided that the Plan 
does not have to pay for anterior instrumentation (22845) provided on April 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services provided on May 15, 2021. 
 
You asked the Plan to pay for the services provided. You say that medical records support the billed services. 
The Plan denied your request. The Plan says no separate payment is made for bundled services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We find that CPT code 99140 is a bundled code. When these services are covered, payment for them is 
subsumed by the payment for the services to which they are incident. 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 anesthesia services provided on May 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on September 
21, 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 denied codes remain not supported. 
 
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 the denied codes is: 
 
CPT 87486: 
 
Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia pneumoniae, amplified probe technique 
 
CPT 87496: 
 
Infectious agent detection by nucleic acid (DNA or RNA); cytomegalovirus, amplified probe technique CPT 87498: 
 
Infectious agent detection by nucleic acid (DNA or RNA); enterovirus, amplified probe technique, includes 
reverse transcription when performed 
 
CPT 87502: 
 
Infectious agent detection by nucleic acid (DNA or RNA); influenza virus, for multiple types or sub-types, 
includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, first 2 
types or sub-types 
 
CPT 87532: 
 
Infectious agent detection by nucleic acid (DNA or RNA); Herpes virus-6, amplified probe technique 
 
CPT 87541: 
 
Infectious agent detection by nucleic acid (DNA or RNA); Legionella pneumophila, amplified probe technique 
 
CPT 87581: 
 
Infectious agent detection by nucleic acid (DNA or RNA); Mycoplasma pneumoniae, amplified probe 
technique 
 
CPT 87634: 
 
Infectious agent detection by nucleic acid (DNA or RNA); respiratory syncytial virus, amplified probe 
technique 
 
CPT 87640: 
 
Infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, amplified probe technique 
 
CPT 87798: 
 
Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, 
each organism 
 
We find that the various denied codes are not supported in the medical record. Specifically, the place of service 
on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim 
reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a 
doctor's office (POS 11). 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 pay for laboratory services 
provided to the enrollee on September 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says until the safety and efficacy of this device has been established, it cannot be approved. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the enrollee indicates that the enrollee has chronic low back pain and lumbar spinal 
stenosis with neurogenic claudication. The record indicates that the enrollee has a body mass index of 40.7. 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the expandable controller, expandable controller 
harness, electronic connection and seat elevator. 
 
You asked the Plan to pre-approve the wheelchair accessories. You say that you would like reconsideration 
because the requested accessories are medically necessary. The Plan denied your request. The Plan says the 
member does not meet Medicare criteria for coverage of the requested accessories. 
 
The Plan follows Medicare rules. Medicare rules say that a power seat elevation feature (E2300) and power 
standing feature (E2301) are non-covered because they are not primarily medical in nature. The rules also say 
that the expandable controller is capable of accommodating one or more of the additional functions listed in the 
Medicare rules section of this letter. 
 
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 accessories. Our 
reviewer says that the documentation does not reveal that the member requires other types of proportional input 
devices or non-proportional input devices. The member does not need to operate 3 or more powered seating 
actuators through the drive control, a  separate display, or an attendant control. The member's strength and 
function in the upper extremities supports that the member can control any power options through their own 
individual switches. Our physician reviewer found the power seat elevation feature (E2300) is non-covered 
because it is not primarily medical in nature. 
 
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 accessories have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the expandable controller, expandable controller harness, electronic 
connection and seat elevator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the first intraoral periapical x-ray (D0220) and crown 
(D2740) provided on May 25, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay more for the first intraoral periapical x-ray and crown. You say that according to the 
Plan the provider was listed as in-network. You also say that you had no way of knowing the provider was 
OON. The Plan denied your request. The Plan says the treating provider does not have a contract with the Plan 
as a participating provider and is allowed to bill the difference of the allowed amount and their billed amount to 
you. The Plan also says that you are responsible for a 50% coinsurance of the allowed amount minus your $100 
annual deductible for the crown. 

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, you are responsible for a 50% 
coinsurance of the covered plan allowance for crowns after the $100 deductible is met. You are also 
responsible for the difference between the Plan's billed amount and the allowed amount for the services having 
been received OON. Therefore, we decided that the Plan does not have to pay more for the first intraoral 
periapical x-ray (D0220) and crown (D2740) provided on May 25, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the intracept procedure (CPT code(s): C9752, 22899), 
for the enrollee. 
 
You asked the Plan to pre-approve the intracept procedure. You say that the enrollee has tried and failed 
conservative treatment without relief. The Plan denied your request. The Plan says the services are considered 
experimental and 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 intracept 
procedure. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the intracept procedure is experimental. More research is 
needed to show safety and efficacy. 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 intracept procedure have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the intracept procedure (CPT code(s): C9752, 
22899), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the external electrocardiographic recording provided on May 
6, 2021.  
You asked the Plan to pay for the diagnostic testing. The Plan denied your request. The Plan says this is not a 
covered screening test. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The testing at issue in this appeal, the external electrocardiographic recording, was requested solely for 
screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided 
that the Plan does not have to pay for the external electrocardiographic recording provided on May 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 20, 2021. 
 You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are 
not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this 
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab 
services provided on June 20, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for resin-based composites - posterior (D2391 and D2393), and a tooth 
extraction (D7210) provided by a participating provider on September 16, 2020, to November 2, 2020. 
 
You asked the Plan to pay for resin-based composites - posterior and a tooth extraction. You say that you were 
told that all the charges would be covered. The Plan denied your request. The Plan says that the enrollee has 
already met their dental allowance for the year. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has failed to send in evidence to show that the member's dental 
allowance was already met at the time of these services. Therefore, we decided that the Plan has to pay for 
resin-based composites - posterior (D2391 and D2393), and a tooth extraction (D7210) provided by a 
participating provider on September 16, 2020, to November 2, 2020.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) scan of the abdomen and 
pelvis for the enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says the first most appropriate step would be to confirm the eradication of the infection. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 pre-approve the scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found the record indicates that 
the enrollee has dyspepsia and was treat for Helicobacter pylori. The record does not indicate the result of 
endoscopy. The provided records do not indicate the medical necessity or reasonableness, as defined by 
Medicare rules, of the requested service. 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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve computed tomography (CT) scan of the abdomen and pelvis for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the hysteroscopy biopsy surgery (58558) 
provided on April 5, 2021. 
 
You asked the Plan to waive the copayment for a hysteroscopy biopsy surgery. You say that you cannot afford 
to pay the copayment. The Plan denied your request. The Plan says the copayment applied correctly based on 
the services rendered. 
 
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 $325 
copayment for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
You have been asked to pay a $325 copayment for a hysteroscopy biopsy surgery. Hysteroscopy biopsy 
surgery falls within the Outpatient surgery, including services provided at hospital outpatient facilities and 
ambulatory surgical centers 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 the hysteroscopy biopsy surgery (58558) 
provided on April 5, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department services coded as 99285 provided 
on April 23, 2021. 
 
You asked the Plan to pay for the emergency department services. You say that the documentation supports the 
CPT code as billed. The Plan denied your request. The Plan says the medical documentation does not support 
the services 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. 
 
In this case, the CPT Code Manual definition of code 99285 is emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. Counseling and/or coordination of care with 
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature 
of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function. 
 
We asked our coder 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 emergency department services. Our reviewer says that 
the medical documentation does not support the code as billed. Our reviewer found the review indicates that 
the enrollee was evaluated for symptoms of abdominal pain, chest pain nausea and vomiting. He was found to 
be positive for the coronavirus. He had laboratory studies, chest X-ray, and computed tomography scan of the 
chest. He was diagnosed with pneumonia and discharged home on medical therapy. The review has determined 
that the medical records did not support the billed CPT code 99285 over the Plan's recommended billing of 
99284. Specifically, the presenting problem(s) were not of high severity and posed an immediate significant 
threat to life or physiologic function. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the emergency department services have not been met. Therefore, we decided 
that the Plan does not have to pay for the emergency department services coded as 99285 provided on April 23, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral evaluation (D0120), and periodontal scaling (D4341, 
D4342), provided on July 6, 2021. 
 
You asked the Plan to pay for the oral evaluation, and periodontal scaling. You say that the service should be 
covered. The Plan denied your request. The Plan says you received services through an out-of-network 
provider. 
 
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 among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the oral 
evaluation (D0120), and periodontal scaling (D4341, D4342), provided on July 6, 2021.