Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve Intracept procedure. You say that this procedure fills a treatment gap for 
patients that do not receive adequate relief from conservative measures and do not have instability to indicate 
fusion is appropriate. The Plan denied your request. The Plan says there is little evidence to suggest that this is 
appropriate for the enrollee. 
 
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 Intracept procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental, more research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Intracept procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Intracept procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for cataract removal provided on August 08, 
2022. 
 
You asked the Plan to reduce the copayment for cataract removal. You say that the copayment should be $295. 
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 $395 
copayment for Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers. 
 
You have been asked to pay a $395 copayment for cataract removal. This item/service falls within the 
Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory 
Surgical Centers benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to reduce the copayment for cataract removal 
provided on August 08, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction provided on September 20, 2022. 
 You asked the Plan to pay for eye refraction. You say that this exam was a follow-up to surgery. The Plan 
denied your request. The Plan says you previously had an eye refraction on May 24, 2022, so this benefit was 
exhausted. 
 
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 1 refraction per calendar year. 
 
We looked at the file and the Plan's rules. You previously received a covered refraction on May 24, 2022; 
therefore, this benefit was exhausted for the 2022 calendar year. Based on this information, we decided that the 
Plan's rules for coverage of eye refraction have not been met. Therefore, we decided that the Plan does not have 
to pay for an eye refraction provided on September 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental crowns (D2740 and D2750) and a core build-up 
(D2950). 
 
You asked the Plan to pre-approve dental crowns and a core build-up. You say that these services are medically 
necessary. The Plan denied your request. The Plan says the provider has failed to send in dental records. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 dental crowns and a core build-up have 
been met. The provider has failed to provide documentation as to why the treatment being requested was 
medically necessary. Therefore, we decided that the Plan does not have to pre-approve dental crowns (D2740 
and D2750) and a core build-up (D2950).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on August 31, 2022. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for office visit provided on 
August 31, 2022.
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. You say that the enrollee would benefit from the services to help 
improve functional mobility. The Plan denied your request. The Plan says ongoing skilled care can be provided 
in an alternative setting. 
 
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 the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anti-reflective coating (V2750), polycarbonate or equal 
lens (V2784), or pay more for the bifocal lens (V2203) provided on September 21, 2022. 
 
You asked the Plan to pay for the anti-reflective coating, polycarbonate or equal lens, and to pay more for the 
bifocal lens. You say that you do not have any extra money to afford these glasses. You also say that they are 
for a medical benefit for you. The Plan denied your request. The Plan says you have a $100.00 plan coverage 
limit for eyewear every year, and the benefit maximum was reached. 
 
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 $100.00 for supplemental eyewear every year. 
 
 
  We looked at the file and the Plan's rules. The record shows that your full eyewear allowance was exhausted on 
the glasses you purchased on this date of service. Based on this information, we decided that the Plan's rules for 
coverage of the anti-reflective coating, polycarbonate or equal lens, or pay more for the bifocal lens have not 
been met. Therefore, we decided that the Plan does not have to pay for the anti-reflective coating (V2750), 
polycarbonate or equal lens (V2784), or pay more for the bifocal lens (V2203) provided on September 21, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the three dimensional (3D) rendering with interpretation and 
reporting (76377) provided on May 16, 2022. 
 
You asked the Plan to pay for the 3D rendering with interpretation and reporting. You say that you would like 
this claim to be reprocessed for payment. The Plan denied your request. The Plan says this service is not 
covered separately by Medicare as it is contained in the authorized radiologic procedure. The Plan also says 
radiologic techniques using 3D-rendering will be considered integral to the radiology services and not a 
separate service. 
 
The Plan must follow Medicare rules. Medicare rules say that it is expected that there should be an order for the 
3D image, or interpreting physician should clearly state in the interpretation the medical necessity for this 
separate service, in addition to the base procedure.  
 
 
 We looked at the file and Medicare rules. Specifically, there was no documentation of an order for the 3D 
image nor documentation by the interpreting physician that the 3D interpretation was medically necessary. 
Based on this information, we decided that Medicare rules for coverage of the 3D rendering with interpretation 
and reporting have not been met. Therefore, we decided that the Plan does not have to pay for the three 
dimensional (3D) rendering with interpretation and reporting (76377) provided on May 16, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for cataract surgery provided on June 27, 2022, 
to July 11, 2022. 
 
You asked the Plan to waive the copayment for cataract surgery. You say that you were told the location of 
your surgery was changed; however, you were not told there would be an additional charge. You feel you 
should not have to pay the billed charges. 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 $450 
copayment for Outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $450 copayment for cataract surgery. This item/service 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 cataract surgery provided on June 27, 2022, to July 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction of an erupted tooth or exposed root (D7140) 
and the surgical placement of implant body (D6010) provided on August 29, 2022. 
 
You asked the Plan to pay for the extraction of an erupted tooth or exposed root (D7140) and the surgical 
placement of implant body (D6010). You say that this was in fact a surgery performed due to legitimate health 
concerns and not a cosmetic procedure. You also say that this surgery involved the jaw and related structures 
and thus should be covered. The Plan denied your request. The Plan says based on Medicare guidelines, the 
dental services being requested do not meet the requirements for Medicare approval. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the extraction of an erupted tooth 
or exposed root (D7140) and the surgical placement of implant body (D6010) provided on August 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extractions (D7210) and the consultation (D9310) for 
tooth #12 and #32 provided on September 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that the Plan told you that the appointment would be 
covered. The Plan denied your request. The Plan says the extractions that were received from an out-of-
network provider and are not covered by your supplemental benefits. The denial of payment for the 
consultation is correct because it is not covered by the Plan. Also, there were no calls from the enrollee or 
provider advising that the provider was an in-network provider or that an exception would be made. 
 
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 extractions from an out-of-network provider. Though the Plan offers a 
dental benefit in excess of Medicare coverage, the extractions are not covered under this benefit when received 
from an out-of-network provider. The consultation is not covered under the Plans dental benefit.  Therefore, 
we decided that the Plan does not have to pay for the extractions (D7210) and the consultation (D9310) for 
tooth #12 and #32 provided on September 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
(87798, 87653, 87640) provided on October 4, 2021. 
 
You asked the Plan to pay for the urine PCR testing. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the PCR testing is considered unproven and not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that urinalysis is the standard of care for urinary tract 
infection (UTI). 
 
We looked at the file and Medicare rules. The file shows that the services at issue exceeded the standard of care 
for the diagnosis and treatment of a UTI. Based on this information, we decided that Medicare rules for 
coverage of the urine PCR testing have not been met. Therefore, we decided that the Plan does not have to pay 
for the urine polymerase chain reaction (PCR) panel testing (87798, 87653, 87640) provided on October 4, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 69209 provided on August 21, 2022. 
 
You asked the Plan to pay for procedure code 69209. 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 must report services correctly. 
 
We looked at the file and Medicare rules. In this case, the enrollee received services (69209) while in an 
outpatient hospital setting. Per Medicare payment guidelines, code 69209 has a PC/TC indicator of 5 and payment may not be made for this code when provided to patients in an outpatient hospital setting. Therefore, 
we decided that the Plan does not have to pay for procedure code 69209 provided on August 21, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron 4MG tablet. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says Ondansetron tablet is a self-administered drug and does not fall under Part B 
coverage. 
 
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 pre-approve Ondansetron 4MG tablet.   
Benefits for the medication 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an osteogenesis stimulator. 
 
You asked the Plan to pre-approve an osteogenesis stimulator. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the requested device is not medically necessary. 
The Plan follows Medicare rules. Medicare rules say that a non-spinal electrical osteogenesis stimulator 
(E0747) is covered only if any of the following criteria are met: 1. Nonunion of a long bone fracture (see Appendices section) defined as radiographic evidence that fracture 
healing has ceased for three or more months prior to starting treatment with the osteogenesis stimulator, or 
2. Failed fusion of a joint other than in the spine where a minimum of nine months has elapsed since the last 
surgery, or 
3. Congenital pseudarthrosis. 
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 an osteogenesis stimulator. Our 
reviewer says that the documentation does not support that the requested device is medically reasonable or 
necessary. Our physician reviewer found the enrollee was being treated for an unspecified fracture of the shaft 
of the unspecified fibula. Conservative treatment included physical therapy, pain management, and casting. 
However, the provided documentation does not support a diagnosis of a non-union of the fibular fracture. The 
most recent x-rays from October 10, 2022, state concern for non-union. Therefore, the enrollee does not have 
a diagnosis/condition that meets the criteria for the requested device. Therefore, the enrollee does not meet 
criteria for the requested device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an osteogenesis stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an osteogenesis stimulator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis (D1110) provided on September 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that you need these services to be covered more 
frequently. 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 17, 2022, and 
June 21, 2022. Therefore, we decided that the Plan does not have to pay for prophylaxis (D1110) provided on 
September 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional periapical x-rays (D0230) and an occlusal 
adjustment (D9951) provided on September 27, 2022. 
 
You asked the Plan to pay for the x-rays and an occlusal adjustment. You say that you should not be 
responsible for these charges considering this was an emergency. The Plan denied your request. The Plan says 
that an occlusal adjustment (D9951) is not covered by your supplemental dental benefits. The Plan also says 
that your benefit for a periapical x-ray 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, an occlusal adjustment is not among 
those covered under this benefit. The record shows your benefit for a periapical x-ray was exhausted on date of 
service September 27, 2022. Therefore, we decided that the Plan does not have to pay for the additional 
periapical x-rays (D0230) and an occlusal adjustment (D9951) provided on September 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on April 25, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services 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 subsequent nursing facility care provided on April 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge day management (99238) provided on 
January 19, 2022. 
 
You asked the Plan to pay for the evaluation and management service. You say that the service was medically 
necessary. 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 hospital discharge day management (99238) provided on 
January 19, 2022.