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

 
We decided that the Plan does not have to pre-approve wheelchair options and accessories. 
 
You asked the Plan to pre-approve the requested items. The Plan denied your request. The Plan says the power 
options can be controlled through their own switches. 
 
The Plan follows Medicare rules. Medicare rules say that wheelchair options and accessories are only covered 
under certain medical indications.  
 
The file shows that an expandable control system was requested. 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 requested items. Our physician reviewer found that the enrollee has 3 power options 
of tilt, recline, and power elevating leg rests. However, the enrollee does not need to control the power options 
through a joystick. The enrollees upper extremity strength supports that the patient can control any power 
options through their own switches. Therefore, the request is not medically reasonable or necessary.  
 
The file shows that a transit system and a power seat elevation system were requested. These items are non-
covered because they are 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 have not been met. 
Therefore, we decided that the Plan does not have to pre-approve wheelchair options and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an aflibercept injection provided on March 
31, 2022. 
 
You asked the Plan to waive the coinsurance for an aflibercept injection. You say that three separate sales 
associates verified that the member's eye injection would be fully covered. You also say that you are now 
receiving bills for the 20% coinsurance of the Part B medication. The Plan denied your request. The Plan says 
you were 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 20% 
coinsurance for Medicare Part B drug.  
 
 You have been asked to pay $732.60 in coinsurance, which is 20% coinsurance of the allowed amount for an 
aflibercept injection ($3,662.99 x 20% = $732.60). An aflibercept injection falls within the Medicare Part B 
drug 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 an aflibercept injection 
provided on March 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an injection and office visit provided on October 19, 2021 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the injection and office visit. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and prior authorization was not obtained. 
 
  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an injection and office visit provided on October 
19, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telephone evaluation services provided on May 16, 2022 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by an out-of-network provider without 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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the telephone evaluation services provided on May 
16, 2022 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a baroreceptor stimulator implant (C1825, 0266T). 
 
You asked the Plan to pre-approve the neurostimulator. You say that this procedure is medically necessary. The 
Plan denied your request. The Plan says this device is considered experimental and is non-covered. 
 
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 neurostimulator. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested stimulator is considered investigational at this time. More research is needed to 
show safety and efficacy for the enrollee's condition. 
 
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 neurostimulator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a baroreceptor stimulator implant (C1825, 0266T).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient admission for surgery. 
 
You asked the Plan to pre-approve inpatient admission. You say that the requested inpatient admission is a 
medical necessity for you. The Plan denied your request. The Plan says medical-necessity rules for inpatient 
admission have not been met. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. 
 
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 inpatient admission. Our reviewer says that the documentation does not support that the criteria for inpatient admission are met in this case. Our 
physician reviewer found that detailed documentation is not evident in the case record regarding a significant 
past and/or current medical history that would place you at increased risk for peri-surgical complications 
requiring an inpatient stay. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve inpatient admission for surgery.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mass spectrometry and tandem mass spectrometry 
(83789) provided on May 13, 2021. 
 
You asked the Plan to pay for code 83789. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
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 the billed code is 
considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does 
not have to pay for the mass spectrometry and tandem mass spectrometry (83789) provided on May 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on May 
10, 2022. 
 
You asked the Plan to pay for the dental services. You say that the service should 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 March 9, 2022. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on May 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the osseous surgery (D4260) provided on April 19, 2022. 
 
You asked the Plan to pay for the dental service. You say that the plan paid for this service in 2021. You say 
that the Evidence of Coverage includes some periodontal services including root planing and scaling. You also 
say that this service should be covered. The Plan denied your request. The Plan says osseous surgery for four or 
more contiguous teeth per quadrant is not listed as a covered service. 
 
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 osseous surgery for four or more 
contiguous teeth per quadrant is not among those covered under this benefit. Therefore, we decided that the 
Plan does not have to pay for the osseous surgery (D4260) provided on April 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for five core build up procedures and four crowns provided on 
November 25, 2020. 
 
You asked the Plan to pay for core build up and four crowns. You say that these services were medically 
necessary due to damage caused by your cancer treatments. The Plan denied your request. The Plan says core 
build up is not covered by your dental benefits. The Plan also says that your benefit for crowns has 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, core build up is not among those 
covered under this benefit. The record shows the Plan agreed to pay for one crown procedure provided on 
November 25, 2020; therefore, your benefit for crowns has been exhausted. We decided that the Plan does not 
have to pay for five core build up procedures and four crowns provided on November 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation (D9310) provided on April 29, 2022. 
 
You asked the Plan to pay for a consultation. You say that you disagree with the denial of dental services. The 
Plan denied your request. The Plan says a consultation (D9310) is not covered by your routine dental 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. 
 
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 a 
consultation (D9310) provided on April 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hereditary cardiovascular screening panel provided on 
December 10, 2020. 
 
You asked the Plan to pay for the testing services. You say that the treatment sought was medically necessary 
to treat the enrollee. The Plan denied your request. The Plan says the screening panel does not meet Medicare 
criteria. 
 
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. 
 
We looked at the file and the rules. The testing services were requested for screening purposes. Medicare does 
not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
hereditary cardiovascular screening panel provided on December 10, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on May 4, 2021. 
 You asked the Plan to pay for 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 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 test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on May 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete series of radiographic images (D0210), and two-
dimensional oral/facial photographic images (D0350 x4) provided on May 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the charges. The Plan denied 
your request. The Plan says your benefit for the complete series of radiographic images has already been 
exhausted, and two-dimensional oral/facial photographic images are not a covered 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, certain limitations apply. The record 
shows your benefit for the compete series of radiographic images was exhausted on date of service May 10, 
2022. Additionally, two-dimensional oral/facial photographic images are not a covered benefit. Therefore, we 
decided that the Plan does not have to pay for a complete series of radiographic images (D0210), and two-
dimensional oral/facial photographic images (D0350 x4) provided on May 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99213) provided on March 22, 2022 by
an out-of-network (OON) provider.

You asked the Plan to pay for the physician services. You say that this service was medically necessary and
should be covered. The Plan denied your request. The Plan says the service was not pre-authorized or
emergent. There were network providers available.

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 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 physician services (99213) provided on March 22, 2022 by an out-of-
network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on May 
4, 2022. 
 
You asked the Plan to pay for the dental service. You say that you were never advised that the oral evaluation 
would not 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 comprehensive oral evaluation was exhausted on date of service August 12, 2021. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) 
provided on May 4, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the maxillary partial denture (D5225) and mandibular partial denture 
(D5226) provided on May 27, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the maxillary and mandibular partial dentures. You say that you would like this 
claim to be reconsidered for coverage. The Plan denied your request. The Plan says that services performed in a 
dental laboratory are not covered under your dental coverage. 
 
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.  
 
We looked at the file and Medicare rules. The record shows that you received maxillary and mandibular partial 
dentures. The Evidence of Coverage (EOC) states that partial flexible base dentures are a covered benefit. 
There is no indication that these dentures would not be covered in the 2022 EOC. Based on this information, 
we decided that the Plan's rules for coverage of the maxillary and mandibular partial dentures have been met. 
Therefore, we decided that the Plan has to pay for the maxillary partial denture (D5225) and mandibular partial 
denture (D5226) provided on May 27, 2022, by an out-of-network (OON) provider.  
 
 
 
 
 
 
 
 
 
 
 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided on February 3, 2022, 
and February 7, 2022, by an out-of-network (OON) provider. 
 You asked the Plan to pay for the skilled nursing services. You say that there is no requirement for a referral or 
prior authorization for the services you provide, and you would like the claim to be fully paid. The Plan denied 
your request. The Plan says the rendering provider is an OON provider and there was no referral from an in-
network provider or an approved authorization. Also, the service rendered was not urgent or emergent. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided on February 
3, 2022, and February 7, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone marrow aspirate. 
 
You asked the Plan to pre-approve a bone marrow aspirate. You say that the records provided support the need 
for a bone marrow aspirate. The Plan denied your request. The Plan says the clinical value and effectiveness of 
bone marrow aspirate in the setting of spinal fusion surgery have not been demonstrated in the peer-reviewed 
literature. 
 
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 a bone marrow aspirate. Our reviewer 
says that a bone marrow aspirate is not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspirate remains experimental. More research is needed. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a bone marrow aspirate.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76000 billed for date of service April 22, 
2021. 
 You asked the Plan to pay for procedure code 76000. You say that you sent medical records, and the code 
should not be denied. The Plan denied your request. The Plan says payment for code 76000 is bundled into 
payment for code 52332. 
 
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 76000 
is a column II code to column I code 52332. 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 76000 billed for date of service April 22, 2021.