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

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you would like to appeal the SSBCI 
attestation form since it got denied. The Plan denied your request. The Plan says the criteria for eligibility have 
not been met. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for psychotherapy provided from June 13, 2022, to 
August 22, 2022. 
 
You asked the Plan to reimburse you for psychotherapy. You say that previous claims have been processed and 
paid for this provider for five years. The Plan denied your request. The Plan says this provider is not a 
Medicare-Certified provider. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to reimburse you for 
psychotherapy provided from June 13, 2022, to August 22, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on April 10, 2022. 
 
You asked the Plan to pay for self-administered drugs. You say that you should not be responsible for the 
charges. The Plan denied your request. The Plan says self-administered drugs are not a covered benefit under 
the members Medicare Part B. The member may submit the service to their part D for reimbursement. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided 
on April 10, 2022.  
 
Benefits for self-administered drugs 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services provided on September 16, 2022. 
 
You asked the Plan to pay for radiology services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says the benefit for this service is included in the 
payment of another service. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of radiology services provided have been 
met. Specifically, missing complete medical records to establish if the service was inclusive to another 
procedure. Therefore, we decided that the Plan does not have to pay for radiology services provided on 
September 16, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 43248 billed for date of service September 
29, 2022. 
 
You asked the Plan to pay for procedure code 43248. You say that the services were medically necessary. The 
Plan denied your request. The Plan says payment for code 43248 is bundled into payment for code 43270. 
 
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 43248 is a column II code to column I code 43270 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 43248 billed for date of service September 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74174 billed for date of service May 26, 
2022. 
 
You asked the Plan to pay for procedure code 74174. You say that the services were medically necessary. The 
Plan denied your request. The Plan says payment for code 74174 is bundled into payment for code 75635. 
 
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 74174 
is a column II code to column I code 75635 with a modifier indicator of 0. The column II code is therefore not payable. 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 74174 billed for date of service May 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental surgical services to prepare for future implants. 
 
You asked the Plan to pre-approve dental surgical services. You say that the requested services are a medical 
necessity for you. The Plan denied your request. The Plan says the requested services are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services in connection with the care, 
treatment, filling, removal, or replacement of teeth or structures directly supporting the teeth are not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of dental surgical services have not been met. Specifically, services rendered in preparation for future 
implants are not a covered medical benefit. Therefore, we decided that the Plan does not have to pre-approve 
dental surgical services to prepare for future implants.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiological services provided on July 16, 2022. 
 
You asked the Plan to pay for radiology services provided. You say that the claim was billed claimed correctly 
and should be paid. The Plan denied your request. The Plan says the billed code is missing the required 
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, the CPT Code Manual definition of code 73562 is radiologic examination, knee; 3 views. 
 
We find that CPT code 73562 is not supported in the medical record. Specifically, this code is missing the LT 
modifier. Based on this information, we decided that Medicare rules for coverage of radiology services 
provided have not been met. Therefore, we decided that the Plan does not have to pay for radiological services 
provided on July 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99291 & 92960 billed for date of service 
August 5, 2022. 
 
You asked the Plan to pay for procedure codes 99291 & 92960. You say that these services were medically 
necessary. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed. Code 92960 is bundled and not separately payable. 
 
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 99291 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Code 92960 is a Column II code to code 99291 and is not separately payable. Based 
on this information, we decided that Medicare rules for coverage of procedure codes 99291 & 92960 have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure codes 99291 & 92960 billed 
for date of service August 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for Medicare Part B prescription drugs and a 
specialist office visit provided on April 9, 2021. 
 
You asked the Plan to waive the cost share for Medicare Part B prescription drugs and a specialist office visit. 
You say that you disagree with the cost share. 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% 
coinsurance for Medicare Part B prescription drugs and a $45 copayment for physician/practitioner 
services/specialist.  You have been asked to pay a 20% coinsurance for Medicare Part B prescription drugs and a $45 copayment 
for a specialist office visit. The total allowed amount for the prescription drugs is $131.50. You are being asked 
to pay $26.30 ($131.50 x 20% = $26.30).The total amount you are being asked to pay is $71.30 ($26.30 + $45 
= $71.30). This item/service falls within the Medicare Part B prescription drugs and physician/practitioner 
services/specialist 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 cost share for Medicare Part B 
prescription drugs and a specialist office visit provided on April 9, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 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 step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found that the enrollee has a diagnosis of 
other osteoporosis without current pathological fracture. She has not tried and failed the Plan's required drugs; 
alendronate, risedronate, or ibandronate, and zoledronic acid or Prolia. The records do not show that the 
required drug would be contraindicated or less effective; therefore, Evenity is not reasonable or medically 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Evenity.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on November 3, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to be reimbursed for the services 
you paid for. You were not aware you had to get prior authorization before seeing the provider. The Plan 
denied your request. The Plan says the dental services were received from an out-of-network provider and are 
not covered by your supplemental benefits. 
 
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. 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for dental services provided on November 3, 2022.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure codes 73552-26-RT and 73552-26-LT billed for 
date of service November 15, 2022. 
 
You asked the Plan to pay for procedure code 73552-26-RT and 73552-26-LT. You say that the claim was 
billed correctly and should be paid The Plan denied your request. The Plan says the number of units billed 
exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT codes 73552-26-RT and 73552-26-LT is 2. The MAI value for this code is 3. 
You billed 4 units of this code, exceeding the MUE. You did not provide all the required evidence showing that 
the excess units were actually provided, were correctly coded, and were medically necessary. Based on this 
information, we decided that Medicare rules for coverage of procedure code 73552-26-RT and 73552-26-LT 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 73552-26-RT 
and 73552-26-LT billed for date of service November 15, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77062 billed for date of service September 9, 
2022. 
 
You asked the Plan to pay for procedure code 77062. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
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 code 77062 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 77062 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 77062 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 77062 billed for date of service September 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on October 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not told or aware that the provider was 
out-of-network. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental benefits. 
 
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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for dental services provided on October 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on November 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that you broke a tooth and had to get it fixed. You 
were told you could be reimbursed for the services, but your paperwork has been denied. The Plan denied your 
request. The Plan says the dental services were received from an out-of-network provider and are not covered 
by your supplemental benefits. 
 
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. 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for dental services provided on November 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
November 19, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service November 19, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mental health care to be provided by a licensed mental 
health counselor. 
 
You asked the Plan to pre-approve mental health care. You say that the requested provider is the only provider 
that understands your condition. The Plan denied your request. The Plan says the requested provider is not 
enrolled in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pre-approve mental health care to be provided 
by a licensed mental health counselor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the manual therapy (97140) provided on November 2, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit by 
Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the manual therapy (97140) provided on November 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (80307) provided on October 14, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the out-of-network services were not emergent or pre-authorized. 
 
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 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 services. Therefore, 
we decided that the Plan does not have to pay for lab services (80307) provided on October 14, 2022, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the porcelain/ceramic crown (D2740) provided on January 6, 2023. 
 
You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says that you have exhausted the allowable benefit for 
this dental item. 
 
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. Specifically, the Plan contract states that a dental crown is covered once every 
five years. The Plan has stated that you have exhausted the allowable benefit for this item as you previously 
received a dental crown on May 24, 2018, less than five years prior. However, the Plan has not provided 
substantive evidence that demonstrates this item was paid for by the Plan. The Plan has not substantiated their 
denial; therefore, we must find in your favor. Therefore, we decided that the Plan has to pay for the 
porcelain/ceramic crown (D2740) provided on January 6, 2023.  
 
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.