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

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150). 
 
You asked the Plan to pre-approve an evaluation. You say that you want to continue seeing this provider as you 
have been seeing him for years. The Plan denied your request. The Plan says dental services received from any 
dental facility other than the assigned contract dentist are excluded from 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. 
 
The Plan confirmed the provider is a non-participating, non-assigned contract dentist. Therefore, we decided 
that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth service billed with code 99451 for date of 
service January 3, 2022. 
 
You asked the Plan to pay for code 99451. You say that you billed this service correctly. The Plan denied your 
request. The Plan says this code is not payable as a telehealth service. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare only pays for certain services under the 
Medicare Physician Fee Schedule when furnished via telehealth.  Medicare publishes a list annually of those 
procedure codes that are payable as telehealth services.  Procedure code 99451 is not listed as a payable 
telehealth service for 2022 on this list. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of code 99451 have not been met. Therefore, we decided that the Plan 
does not have to pay for the telehealth service billed with code 99451 for date of service January 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft and gum surgery tooth 20 
(D7953, D4267) 
 
You asked the Plan to pre-approve the bone replacement graft and gum surgery tooth 20. 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 do not fall within your dental benefits. 
 
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 pre-approve a 
bone replacement graft and gum surgery tooth 20 (D7953, D4267)
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code A4220 billed for date of service December 28, 2021. 
 
You asked the Plan to pay for code A4220. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says this code is not separately payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code A4220 has a status indicator of P on the Physician Fee Schedule. This means that CPT 
code A4220 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of code A4220 have not been met. Therefore, we decided that the Plan does not have to pay for code A4220 
billed for date of service December 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70544-26 billed for date of service February 
7, 2022. 
 You asked the Plan to pay for procedure code 70544-26. You say that the patient had multiple exams on this 
date of service. The Plan denied your request. The Plan says payment for code 70544 is bundled into payment 
for code 70551. 
 
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 procedure code 70544-26 billed for date of service February 7, 
2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a facet block injection. 
 
You asked the Plan to pre-approve a facet block injection. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that facet block injections are covered when specific 
criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a facet block injection. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the LCD criteria require 80% 
pain relief which was not achieved. Therefore, the request is deemed not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a facet block injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a facet block injection.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for the emergency room services provided on June 13, 2021. 
 
You asked the Plan to pay for the services provided. You say that the system is pulling the incorrect provider 
number. The Plan denied your request. The Plan says that this is a duplicate claim. 
 
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. 
 
We looked at the file and the rules. The case file does not contain documentation, such as a claim or 
explanation of benefits to show that the service at issue was previously billed and paid for by the Plan. The 
Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request.  Therefore, we decided that the Plan has to pay for the emergency room services 
provided on June 13, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on February 2, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the home health visit. You say that it is the facilities responsibility to obtain prior 
authorization and you would like the claim reprocessed for payment. 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 a home health visit provided on February 2, 2022, 
by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76700 billed for date of service February 9, 
2022. 
 You asked the Plan to pay for procedure code 76700. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76700 is bundled into payment for 
code 93976. 
 
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 76700 
is a column II code to column I code 93976. 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 76700 billed for date of service February 9, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic manipulative treatment (CMT); spinal provided 
on March 4, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for chiropractic manipulative treatment (CMT); spinal. You say that this member is 
enrolled in a Medicare dual plan and is entitled to all Medicare approved services. The Plan denied your 
request. The Plan says the rendering provider is a non-participating provider and there is no referring provider 
involved in these services. The Plan also says they did not authorize any services for this provider or facility. 
 
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 chiropractic manipulative treatment (CMT); spinal 
provided on March 4, 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 an addition, endoskeletal system, below knee, flexible 
protective outer surface covering system L5962. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the plan approved a replacement socket and other accessories. 
 
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 services. 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 documentation does not support the need for a replacement endoskeletal system or 
an advanced/protective outer surface covering system. There is no documentation of special circumstances that 
would require a protective outer surface covering system. 
 
 
 
  
 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an addition, endoskeletal system, below knee, flexible protective outer surface covering 
system L5962.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for blood smear interpretation (85060) provided on January 28, 
2022. 
 
You asked the Plan to pay for blood smear interpretation. You say that this claim was billed appropriately. The 
Plan denied your request. The Plan says this service was not billed in accordance with Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules say that no payment is recognized for 
CPT code 85060 furnished to hospital outpatients or non-hospital patients. The physician interpretation is paid 
through the clinical laboratory fee schedule payment for the clinical laboratory test. 
 
 We find that CPT code 85060 is not supported in the medical record. Specifically, this claim was billed with 
Place of Service (POS) code 22 (On Campus- Outpatient Hospital). The documentation shows that this service 
was provided to an enrollee who was in an outpatient setting. Based on this information, we decided that 
Medicare rules for coverage of blood smear interpretation have not been met. Therefore, we decided that the 
Plan does not have to pay for blood smear interpretation (85060) provided on January 28, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued occupational therapy (OT) services. 
 
You asked the Plan to pre-approve continued OT services. The Plan denied your request. The Plan says the 8 
OT visits are not medically necessary and that the enrollee does not meet the Medicare Criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 
 
  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 continued OT services. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found the enrollee has previously been treated with outpatient 
therapies and should be independent with a home exercise program. There is no documentation of a recent 
injury or decline in function. Our reviewer also found that the additional therapy services are not an appropriate 
duration and frequency for treatment of the enrollees medical condition and therefore are not 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 continued OT services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued occupational therapy (OT) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for urgent care services (S9083) provided December 19, 2021. 
 
You asked the Plan to pay for the urgent care services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the code billed is not eligible for Medicare payment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code S9083 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code S9083 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of the urgent care services have not been met. Therefore, we decided that the Plan does not have to 
pay for urgent care services (S9083) provided December 19, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the influenza (flu) vaccine (90653), and administration of 
(G0003) provided on October 8, 2021. 
 
You asked the Plan to pay for the physician services. You say that the flu shot is not related to the enrollee's 
hospice diagnosis. The Plan denied your request. The Plan says the enrollees claim would be covered under 
Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the 
last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify 
the enrollees coverage before rendering services and to know proper billing procedures for a Medicare 
Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the influenza (flu) vaccine (90653), and administration of 
(G0003) provided on October 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a three dimensional (3D) rendering with interpretation 
and reporting (76377). 
 
You asked the Plan to pre-approve a 3D rendering. The Plan denied your request. The Plan says there is not 
enough evidence showing the requested study would improve the outcome for your condition. 
 
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 3D rendering. Our reviewer says that 
another 3D rendering not considered medically reasonable and necessary in this case. Our physician reviewer 
found the NeuroQuant analysis is an extra magnetic resonance imaging (MRI) sequence which uses 3D 
rendering to measure hippocampal volume. Such volumetric analysis is important to determine if Alzheimer's 
dementia is present hence providing a valuable tool in diagnosis. Our reviewer found that an extra 3D 
rendering in this case is not indicated. A 3D rendering was provided during the NeuroQuant sequence as part of 
the April 14, 2022 MRI scan. Our physician reviewer also found that another scan and/or 3D rendering should 
be denied as it has already been done. 
 
 
 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 3D rendering have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a three dimensional (3D) rendering with interpretation and reporting (76377).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lens (V2100), frames (V2020), and polycarbonate or 
equal lens (V2784) provided on December 9, 2021. 
 You asked the Plan to pay for the lens, frames, and polycarbonate or equal lens. You say that a Plan 
representative advised that you could get one free pair of glasses per year. You also say that you would not 
have ordered them if you had known you would not be reimbursed because you are on a fixed income and 
cannot afford this expense. The Plan denied your request. The Plan says the Plan has already issued the 
maximum benefit allowance of $150 to the provider. The Plan also says that no further payment from the 
health plan is due. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers up to $150 every year for non-Medicare covered eyewear. 
 
We looked at the file and the Plan's rules. The record shows that you received deluxe frames (V2025) on 
December 9, 2021 which the full $150 allowance was applied toward, and your non-Medicare covered eyewear 
allowance has been exhausted. Based on this information, we decided that the Plan's rules for coverage of the 
lens, frames, and polycarbonate or equal lens have not been met. Therefore, we decided that the Plan does not 
have to pay for the lens (V2100), frames (V2020), and polycarbonate or equal lens (V2784) provided on 
December 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction (92015) provided on February 1, 2022. 
 
You asked the Plan to pay for the eye refraction. You say that you believe this charge should be covered by the 
Plan. The Plan denied your request. The Plan says eye refractions are only covered by your plan if performed 
by a participating provider and performed as a routine screening.  
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when the eye refraction is provided during a routine exam. 
 
We looked at the file and the Plan's rules. The record shows that the Plan confirmed the charges were billed 
with a medical diagnosis of age-related cataract, bilateral for an eye refraction, which is not a routine exam. 
Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not been 
met. Therefore, we decided that the Plan does not have to pay for the eye refraction (92015) provided on 
February 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Domiciliary or rest home visit provided on March 23, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Domiciliary or rest home visit. You say that you are appealing the claim payment 
denial. The Plan denied your request. The Plan says the rendering provider is non-participant, there isn't a 
referring provider, and this is 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 Domiciliary or rest home visit at issue in this appeal. The Plan did not 
pre-approve the Domiciliary or rest home visit 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 Domiciliary or rest 
home visit provided on March 23, 2022, by an out-of-network (OON) provider.