Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the tie downs for transit (K0108), spoke protectors 
(K0065), pneumatic propulsion tires (E2211 and E2213) and non-standard seat frame. 
 
 
 You asked the Plan to pre-approve the tie downs for transit, spoke protectors, pneumatic compression tires and 
non-standard seat frame.. You say that you would like reconsideration because the requested accessories are 
medically necessary. The Plan denied your request. The Plan says the requested equipment does not meet 
criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.  The rules also say that Medicare will pay for durable medical equipment that is needed for 
use in the home.  
 
We looked at your request, the file and Medicare rules. Based on this information we have decided that 
Medicare criteria for coverage of the requested equipment has not been met. Specifically, the transit tie downs 
are not for use in the member's home. The spoke protectors do not service a primary medical purpose. The 
pneumatic tires already come standard on the approved wheelchair and cannot be unbundled for separate 
billing. The records do not support a need for the requested nonstandard seat frame. Therefore, we decided that 
the Plan does not have to pre-approve the tie downs for transit (K0108), spoke protectors (K0065), pneumatic 
propulsion tires (E2211 and E2213) and non-standard seat frame.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says IRF admission is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. It is not clear that the enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Services may 
be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a specialist office visit and a glucose 
monitoring test provided on May 26, 2021. 
 
You asked the Plan to waive the copayments for a specialist office visit and a glucose monitoring test. You say 
that you cannot afford to pay the copayments due to little income. The Plan denied your request. The Plan says 
you have been charged the correct cost sharing amount. 
 
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 $5 copayment for an in-network specialist office 
visit. The Plan contract also says that enrollees must pay up to a $50 copayment for an in-network outpatient 
diagnostic test. 
 
You have been asked to pay a $5 copayment for a specialist office visit. A specialist office visit falls within the 
Physician/Practitioner Services, Including Doctors Office Visits benefit category. You have also been asked to 
pay the allowed amount of $38.67, which is less than the copayment of up to $50 for a glucose monitoring test. 
A glucose monitoring test falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayments for a specialist office visit and a glucose monitoring test 
provided on May 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (70450) provided on October 20, 2021. 
 
You asked the Plan to pay for the services. You say that fasdfsad The Plan denied your request. The Plan says 
this is a bundled service.  
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 the services (70450) provided on October 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for screening mammography, bilateral (2-view study of each 
breast), including computer-aided detection (CAD) (77067) screening digital breast tomosynthesis, bilateral 
(list separately in addition to code for primary procedure) (77063) provided July 2, 2021. 
 
You asked the Plan to pay for the diagnostic service. You say that you have attached medical records to show 
that the service performed was appropriate with diagnosis code. Please review and reprocess the claim for 
payment. The Plan denied your request. The Plan says duplicate procedure/payment. CPT 77067-26*1 and 
77063-26*1 has an MUE value of 1, but 1 unit paid in claim history. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 77067-26 and 77063-26 is 1. The MAI value for this code is 2. You billed 
2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for 
coverage of the diagnostic service have not been met. Therefore, we decided that the Plan does not have to pay 
for screening mammography, bilateral (2-view study of each breast), including computer-aided detection 
(CAD) (77067) screening digital breast tomosynthesis, bilateral (list separately in addition to code for primary 
procedure) (77063) provided July 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the magnetic resonance angiography (MRA) head (70544) 
provided September 14, 2021. 
 
You asked the Plan to pay for the diagnostic service. You say that the enrollee had multiple exams on this date 
of service. Attached reports to support level of service. Please reconsider for processing. The Plan denied your 
request. The Plan says code 70544 has a bundled relationship with code 70551. The claim was not billed with 
an appropriate modifier to bypass this edit with billed together on the same claim. 
 
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 70544 
is a column II code to column I code 70551. 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 the magnetic resonance angiography (MRA) head (70544) 
provided September 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan of the 
neck provided on August 16, 2021. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you cannot afford the copayment due 
to little income. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. 
 
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 up to a 
$50 copayment for each in-network diagnostic radiology service.  
 
You have been asked to pay a $50 copayment for a CT scan. A CT scan falls 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 computed tomography (CT) scan of the neck provided on August 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220) 
provided on November 4, 2021. 
 
You asked the Plan to pay for dental code D0220. You say that you would like the Plan to reconsider your 
request. The Plan denied your request. The Plan says dental code D0220 is not covered under the Plan's 
supplemental dental benefit. 
 
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, dental code D0220 is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the intraoral - 
periapical first radiographic image (D0220) provided on November 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for magnetic resonance imaging (MRI) scans 
provided from October 19, 2021, to November 26, 2021. 
 
You asked the Plan to waive the copayments for MRI scans. You say that you were told you could have these 
covered under one copayment if they were provided on the same day, so these claims should be adjusted so that 
you are only charged one copayment. The Plan denied your request. The Plan says the copayment amounts you 
are being charged are correct. 
 
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 $175 
copayment for each MRI. There were 3 MRI scans, resulting in a total copayment amount of $525. 
 You have been asked to pay $175 copayment for each MRI scan. MRI scans 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 copayments for magnetic resonance imaging (MRI) scans provided from October 19, 2021, to November 
26, 2021.  
 
Your complaint about the issues you experienced with the authorization process is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided by an out-of-network (OON) 
provider on October 14, 2021. 
 
You asked the Plan to pay for the dental services provided by an OON provider. You say that you would like 
the Plan to reconsider your request. The Plan denied your request. The Plan says dental services are not 
covered under the Plan's supplemental dental benefit when provided by an OON provider. 
 
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, dental services provided by an OON 
provider are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for the dental services provided by an out-of-network (OON) provider on October 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two problem focused limited oral evaluations (D0140 x2) 
and first intraoral periapical x-ray (D0220) provided on October 18, 2021, and October 22, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluations and first intraoral periapical x-ray. 
You say that these services are covered under your plan. The Plan denied your request. The Plan says these 
services are not covered expenses under your dental plan. The Plan also says that you did not contact the Plan 
prior to these services being rendered to verify benefits and provider eligibility. 
 
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 two 
problem focused limited oral evaluations (D0140 x2) and first intraoral periapical x-ray (D0220) provided on 
October 18, 2021, and October 22, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for occupational therapy (OT) services 
provided on September 21, 2021. 
 
You asked the Plan to waive the copayment for the OT services. You say that  The Plan denied your request. 
The Plan says you have been charged the correct cost sharing amount. 
 
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 $25 
copayment for each occupational therapy visit.   
You have been asked to pay a $25 copayment for the OT services. The OT 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 
occupational therapy (OT) services provided on September 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lite Spoke wheels, Ergo Scissors, and a side guard for 
an ultralightweight wheelchair. 
 
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 covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The items at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve Lite Spoke wheels, Ergo Scissors, and a side guard for an ultralightweight wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and 
first intraoral periapical x-ray (D0220) provided on November 8, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray. 
You say that you would like to appeal these services. The Plan denied your request. The Plan says these 
services are not covered expenses under your dental plan. 
 
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 
problem focused limited oral evaluation (D0140) and first intraoral periapical x-ray (D0220) provided on 
November 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that you need a consult with this provider for 
treatment. The Plan denied your request. The Plan says this facility is a non-contracted provider and there are 
available in-network providers able to provide care for your condition. 
 
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 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Epifix Allograft (Q4186). 
 
You asked the Plan to pre-approve the Epifix Allograft. You say that this service is medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. The wound has been responsive to 
traditional wound care measures. 
 
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 Epifix Allograft. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found as there was no clear failure of current more conservative treatment for the patients wound, the 
Epifix will be considered not medically necessary at this time.  
 
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 Epifix Allograft have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Epifix Allograft (Q4186).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided by an out-of-network (OON) 
provider on September 20, 2021. 
 
You asked the Plan to pay for the dental services provided by an OON provider. You say that you would like 
the Plan to reconsider your request. The Plan denied your request. The Plan says dental services are not 
covered when provided by an out-of-network (OON) 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, dental services provided by an OON 
provider are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for the dental services provided by an out-of-network (OON) provider on September 20, 2021.  
 
Your complaint about the Plan providing you the incorrect information is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and fluoride application 
(D1206) provided on November 2, 2021. 
 
You asked the Plan to pay for the oral exam and fluoride. You say that you were called by a Plan representative 
and informed that you had 3 cleanings per year. The Plan denied your request. The Plan says they have agreed 
to make an exception and pay for the dental cleaning, but the oral exam and fluoride application exceed the 
frequency limitations of your benefit. 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan can cover two 
routine periodic exams (D0120) per plan year and two fluoride procedures (D1206, D1208) per plan year. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the exam and fluoride are requested in 
a frequency that is not covered under this benefit. While the call logs did show that you were incorrectly told 
that you are covered for three cleanings per year, the record shows that during this call you were given the 
correct information that two fluoride treatments and two exams are covered per year. The record shows that 
you had previous periodic oral exams and fluoride applications in February and June of 2021, which were 
covered by the Plan. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation 
(D0120) and fluoride application (D1206) provided on November 2, 2021.