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

 
We decided that the Plan does not have to pay for the missed appointment (D9986) on August 30, 2022. 
 
You asked the Plan to pay for the missed appointment. You say that you missed your appointment due to lack 
of transportation, and you were unaware there was a cover charge. The Plan denied your request. The Plan says 
this service is not covered under the Plan. 
 
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 the 
missed appointment (D9986) on August 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on October 6, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says 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 physician services provided on October 6, 2022, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the culture, bacterial; quantitative colony count, urine 
(87086) and culture, bacterial; with isolation and presumptive identification of each isolate, urine (87088) 
provided on August 11, 2022. 
 
You asked the Plan to pay for the urine cultures. You say that this claim should be paid. The Plan denied your 
request. The Plan says this testing is not covered for the listed indication. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 87086 and 87088 are covered for listed 
indications. 
 
We looked at the file and Medicare rules. The claim was billed with diagnosis code N32.9 (Bladder 
disorder, unspecified). This code is not listed as a covered diagnosis for 87086 or 87088. Based on this 
information, we decided that Medicare rules for coverage of the urine cultures have not been met. Therefore, 
we decided that the Plan does not have to pay for the culture, bacterial; quantitative colony count, urine 
(87086) and culture, bacterial; with isolation and presumptive identification of each isolate, urine (87088) 
provided on August 11, 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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 there is no documentation to show that the enrollee's functional impairments are 
complex or evidence that the enrollee would significantly benefit from an intensive rehabilitation program. IRF criteria is not met. 
 
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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kyphoplasty. 
 
You asked the Plan to pre-approve Kyphoplasty. You say that the requested Kyphoplasty is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested 
Kyphoplasty. 
 
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 Kyphoplasty. Our reviewer says that 
the enrollee does not meet criteria for the requested Kyphoplasty. Our physician reviewer found there is no 
imaging study showing bone marrow edema and this may not be an acute fracture that is less than 6 weeks old. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Kyphoplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the three office visits provided from 
August 8, 2022, to September 15, 2022. 
 
You asked the Plan to waive the copayments for the three office visits. You say that you keep receiving bills. 
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 $45 
copayment for each Medicare-covered specialist visit. 
 
You have been asked to pay a $135 copayment for the three office visits ($45 x 3 visits = $135). These 
items/services fall within the physician/practitioner services, including doctors office visits benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayments for the three office visits provided from August 8, 2022, to 
September 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 63709 billed for date of service July 26, 
2022. 
 
You asked the Plan to pay for procedure code 63709. You say that the records show the services were 
performed. The Plan denied your request. The Plan says payment for code 63709 is bundled into payment for 
code 63047. 
 
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 63709 is a column II code to column I code 63047. The code at issue 
was billed with the XS modifier. However, the records do not show that the service was a distinct procedural 
service. Based on this information, we decided that the Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 63709 billed for date of service 
July 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99212) provided on September 1, 2022, by a 
chiropractor. 
 
You asked the Plan to pay for the office visit. You say that chiropractic services are covered with a $20 
copayment. You say that your appointment was for a specific reason. You also say that you feel this should be 
paid. The Plan denied your request. The Plan says Medicare does not cover anything other than manual 
manipulation of the spine rendered by a chiropractor. 
 
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 office visit (99212) provided on September 1, 2022, by a chiropractor.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Intracept procedure. 
 
You asked the Plan to pre-approve Intracept procedure. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested services are not medically necessary. 
 
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 services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has chronic low back pain. The Intracept procedure is experimental. More research 
is needed. Therefore, the enrollee does not meet criteria for the requested services. 
 
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 Intracept procedure.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 12, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that these services were medically necessary. 
The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 70496.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 12, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vertiflex device. 
 
You asked the Plan to pre-approve Vertiflex device. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested services are not medically necessary. 
 
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 Vertiflex device. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has lumbar spinal stenosis with neurogenic supereon. The Vertiflex device is 
experimental. More research is needed. Therefore, the enrollee does not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Vertiflex device.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zilretta. 
 
You asked the Plan to pre-approve Zilretta. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Zilretta. Our reviewer says that the 
documentation does not support that Our physician reviewer found the enrollee has a diagnosis of osteoarthritis 
of the knee. The enrollee previously received Zilretta injections in both knees on October 24, 2022. The 
efficacy and safety of repeat administration of Zilretta have not been demonstrated. Thererore, the enrollee 
does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Zilretta have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Zilretta.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87640 billed for date of service October 6, 
2021. 
 
You asked the Plan to pay for procedure code 87640. You say that this service was necessary and is supported 
as billed. The Plan denied your request. The Plan says payment for code 87640 is bundled into payment for 
code 87641. 
 
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 87640 
is a column II code to column I code 87641. 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 87640 billed for date of service October 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - periapical each additional radiographic image 
(D0230) x5, 2D oral/facial photographic image obtained intra-orally or extra-orally (D0350) x4 and one beam 
CT capture and interpretation with field of view of both jaws; with or without cranium (D0367) provided on 
August 22, 2022. 
 You asked the Plan to pay for dental services. You say that you would like the Plan to cover the billed services, 
because your provider passed away and you had to find a new provider. The Plan denied your request. The Plan 
says these services are not covered under your Plan. 
 
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. 2D oral/facial photographic 
image obtained intra-orally or extra-orally (D0350) and one beam CT capture and interpretation with field of 
view of both jaws; with or without cranium (D0367) are not covered under the Plans dental benefits. This 
benefit includes the requested intraoral - periapical each additional radiographic image (D0230) but is limited 
to one procedure code per calendar year. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D0350 and D0367 are 
not among those covered under this benefit. The record shows your benefit for the requested intraoral - 
periapical each additional radiographic image (D0230) was exhausted on date of service August 22, 2022. The 
Plan paid for intraoral - periapical first radiographic image (D0220). Although these are two different services, 
they fall within the same category in your Evidence of Coverage and are subject to the same frequency 
limitations. Therefore, we decided that the Plan does not have to pay for intraoral - periapical each additional 
radiographic image (D0230) x5, 2D oral/facial photographic image obtained intra-orally or extra-orally 
(D0350) x4 and one beam CT capture and interpretation with field of view of both jaws; with or without 
cranium (D0367) provided on August 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the acupuncture treatments (97810) 
provided from June 17, 2022, through July 21, 2022. 
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services 
provided do not meet Medicare criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met.  Specifically, the acupuncture services in this case were not provided on the basis of a diagnosis for chronic low 
back pain. Therefore, we decided that the Plan does not have to issue reimbursement for the acupuncture 
treatments (97810) provided from June 17, 2022, through July 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on July 21, 2022. 
 
You asked the Plan to pay for lab testing. 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 lab testing provided on 
July 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for collection of laboratory specimen provided on November 30, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for collection of laboratory specimen. You say that the reports attached support the 
services provided. The Plan denied your request. The Plan says there was no authorization obtained prior to the 
services being rendered. 
 
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 collection of laboratory specimen provided on 
November 30, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88311 provided on June 24, 2022. 
 
You asked the Plan to pay for procedure code 88311. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly 
denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on August 17, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for procedure code 88311 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 88311 provided on June 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab work provided on September 26, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for lab work. You say that you would like the Plan to pay for this. The Plan denied 
your request. The Plan says the referring provider is not a participating provider. 
 
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 lab work provided on September 26, 2022, by an 
out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve right ankle arthrodesis to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve right ankle arthrodesis to be provided by an OON provider. You say that the 
services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able 
to provide these services. Therefore, coverage criteria have not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
right ankle arthrodesis to be provided by an out-of-network (OON) provider.