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

 
We decided that the Plan does not have to pay for the complex chronic care management services (99487, 
99489) provided on February 26, 2021. 
 
You asked the Plan to pay for the care management services. You say that the claim was filed timely. You say 
that you did not receive a response. You also say that you sent another claim was sent to which you received a 
denial for timely filing. The Plan denied your request. The Plan says the claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the care management services was not filed until April 20, 2022. This means 
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the complex chronic care management services (99487, 99489) 
provided on February 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical mitral valve replacement (33430, 33425). 
 
You asked the Plan to pre-approve surgical mitral valve replacement. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the requested service is 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 surgical mitral valve replacement. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the most recent cardiac imaging in September 2022, showed moderate 
mitral regurgitation. This degree of mitral regurgitation would not be considered severe in this enrollee. As a 
result, at this time the requested surgical mitral valve replacement would not be considered medically necessary 
in this enrollee's clinical management based on the submitted documentation. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of surgical mitral valve replacement have not been met. Therefore, we decided that 
the Plan does not have to pre-approve surgical mitral valve replacement (33430, 33425).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for eye surgery provided on August 24, 2022. 
 
You asked the Plan to waive the copayment for the eye surgery. You say that the service was necessary and 
will save you money. 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 $210 
copayment for surgery or other services provided at an ambulatory surgical center.  
 
You have been asked to pay $138.48, which is less than the $210 copayment for the eye surgery. This 
item/service falls within the surgery or other services provided at an ambulatory surgical center 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 eye surgery provided on August 24, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Barostim Neo System (0266T and C1825). 
 
You asked the Plan to pre-approve a Barostim Neo System. You say that the services are medically necessary. 
The Plan denied your request. The Plan says The clinical value and effectiveness of the Barostim Neo System 
in the setting of congestive heart failure 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 Barostim Neo System. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains an absence of randomized, blinded clinical studies examining long-
term clinical outcomes establishing the value of Barostim Neo in patient management. 
 
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 Barostim Neo System have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Barostim Neo System (0266T and C1825).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the walker provided on September 19, 
2022. 
 
You asked the Plan to waive the coinsurance for the walker. You say that you were told the charge was 
different than what you were billed. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for durable medical equipment, oxygen/oxygen equipment and related supplies. 
 
You have been asked to pay a 20% coinsurance for the walker ($67.68 + $18.65 = $86.33 x .20 = $17.27). This 
item/service falls within the durable medical equipment (DME) and related 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 coinsurance for the walker provided on September 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a re-cement or re-bond implant/abutment supported crown 
tooth # 11 (D6092) provided on September 6, 2022. 
 
You asked the Plan to pay for re-cement or re-bond implant/abutment supported crown tooth # 11. You say that 
your implant crown had gotten loose and the dentist removed it, cleaned and re-cemented it. You also are 
asking for an exception for the service to be covered. The Plan denied your request. The Plan says this service 
is not covered under the benefit package. 
 
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 re-
cement or re-bond implant/abutment supported crown tooth # 11 (D6092) provided on September 6, 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 IRF care is medically necessary. The Plan denied 
your request. The Plan says the IRF care is not medically necessary, and the enrollee's needs can be met at a 
lower level of care such as a skilled nursing facility. 
 
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 documentation shows that the enrollee has functional impairments, however, there are no complex functional deficits. Additionally, the enrollee is medically stable from an outpatient 
standpoint. There are no active medical comorbidities and would not be expected to require inpatient 
hospitalization with an interdisciplinary approach to rehabilitation 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 pre-approve a crown (D2740) for tooth #29. 
 
You asked the Plan to pre-approve a crown. You say that you are not sure why this service is not covered 
because you are paying $18 per month. You also say that at least 50% of this service should be covered. The 
Plan denied your request. The Plan says the allowed charge $995.95 for a crown (D2740) for tooth #29 was 
denied, an alternate benefit of the allowed charge $840.94 for a crown (D2751) for tooth #29 will be applied. 
 
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 service is not denied, but 
rather to be paid on the least costly method of treatment, and you will be responsible for the remaining balance. 
Per your benefit plan you will be responsible for a 50% coinsurance plus the difference between the allowed 
amounts. Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) for tooth #29.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mattress (A9270), and delivery fees and sales tax (S9999), 
provided on September 5, 2022. 
 
You asked the Plan to pay for a mattress, and delivery fees and sales tax. You say that the items should be 
covered. The Plan denied your request. The Plan says this item is for convenience and not medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for a mattress (A9270), and delivery fees and sales tax (S9999), 
provided on September 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the therapeutic continuous glucose monitor (CGM). You say that you need 
this to monitor your sugar levels and would prefer to diet than to take insulin. The Plan denied your request. 
The Plan says you do not require insulin three or more times daily. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of the 
therapeutic continuous glucose monitor (CGM) have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a therapeutic continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300), expandable 
controller (E2377), harness (E2313), and electronic connection (E2311). 
 
You asked the Plan to pre-approve the wheelchair accessories/features. You say that the items are medically 
necessary. The Plan denied your request. The Plan says the power elevating seat system is not a covered item, 
and it is not medically necessary to control power options through a separate joystick. 
 
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 wheelchair accessories/features. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. 
Our physician reviewer found an expandable controller is not needed to operate one power feature. 
 
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 wheelchair accessories/features have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a power seat elevation system (E2300), expandable controller 
(E2377), harness (E2313), and electronic connection (E2311).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of dental implant (41899). 
 
You asked the Plan to pre-approve dental services. You say that the enrollee fell and needs an implant. The 
Plan denied your request. The Plan says this service is 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. Surgical placement of dental 
implant (41899) is not covered under the Plans dental benefits. 
 
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. In addition, you do not have a dental care benefit included in your 
current plan. Therefore, we decided that the Plan does not have to pre-approve surgical placement of dental 
implant (41899).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on April 05, 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 
April 05, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cone beam CT capture (D0383). 
 
You asked the Plan to pre-approve a cone beam CT capture. You say that you would like this to be covered. 
The Plan denied your request. The Plan says the requested dental service is 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, 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 
cone beam CT capture (D0383).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99204 billed for date of service July 14, 
2022. 
 
You asked the Plan to pay for procedure code 99204. You say that the medical documentation support payment 
for this code. The Plan denied your request. The Plan says payment for code 99204 is bundled into payment for 
code 99219. 
 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 99204 
is a column II code to column I code 99219. 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 99204 billed for date of service July 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan with a 
metabolic evaluation. 
 
You asked the Plan to pre-approve the PET scan with a metabolic evaluation. You say that the PET scan is 
medically necessary. The Plan denied your request. The Plan says the medical records provided do not indicate 
that the enrollee meets the diagnostic criteria of both Alzheimer's disease and fronto-temporal dementia. There 
is no indication that the exam is being requested in the context of a clinical trial. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically 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 the PET scan with a metabolic 
evaluation. Our reviewer says that the PET scan with a metabolic evaluation is not medically necessary. Our 
physician reviewer found that the record indicates that the enrollee has normal cognitive testing and drug-
induced parkinsonism. The record provided does not establish a recent diagnosis of dementia and documented 
cognitive decline of at least 6 months, in an enrollee who meets diagnostic criteria for both Alzheimers disease 
(AD) and fronto-temporal dementia (FTD) and that the cause of the clinical symptoms remains uncertain. The 
record does not indicate that the enrollee is enrolled in a qualified clinical trial. The elements of the coverage 
criteria are not satisfied. The requested service is not recommended. 
 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 PET scan with a metabolic evaluation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan with a 
metabolic evaluation.
Appeal type: Drugs
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve 2 levels of diagnostic MBBs. We decided that the Plan does not 
have to pre-approve 1 level of diagnostic MBBs.  
 You asked the Plan to pre-approve 3 levels of diagnostic medial branch blocks (MBBs). You say that the 
services are necessary. The Plan says that based on the documentation provided, coverage criteria have not 
been met. 
 
We decided that the Plan has to pre-approve 2 levels of diagnostic MBBs.  
 
The Plan follows Medicare rules. Medicare rules say that one to two levels, either unilateral or bilateral, are 
allowed per session per spine region. 
 
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 2 levels of diagnostic MBBs. Our 
reviewer says that the services are medically necessary. Our physician reviewer found 2 levels of diagnostic 
MBBs are medically reasonable and necessary. There are no extraordinary circumstances that are documented 
to explain why utilization criteria should be exceeded. The request for a third level is not medically reasonable 
and 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 2 levels of diagnostic MBBs have been met. Therefore, we decided that the Plan 
has to pre-approve 2 levels of diagnostic MBBs.  
 
We also decided that the Plan does not have to pre-approve 1 level of diagnostic MBBs. 
 
The Plan follows Medicare rules. Medicare rules say that one to two levels, either unilateral or bilateral, are 
allowed per session per spine region.  
 
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 1 level of diagnostic MBBs. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found 2 levels of diagnostic 
MBBs are medically reasonable and necessary. There are no extraordinary circumstances that are documented 
to explain why utilization criteria should be exceeded. The request for a third level is not medically reasonable 
and 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 1 level of diagnostic MBBs have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 1 level of diagnostic MBBs. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code E0730 billed for date of service July 18, 2022. 
 
You asked the Plan to pay for code E0730. You say that the provided documentation supports payment for this 
item The Plan denied your request. The Plan says you did not provide a valid proof of delivery for this item. 
 
The Plan must follow Medicare rules. The rules state that for shipped durable medical equipment, the date of 
service can either be the date of delivery or the date of shipping.   
The record does not contain a valid proof of delivery, or relevant medical records which support medical 
necessity for the supplies provided in this case. Specifically, while you did provide United States Postal Service 
tracking information, the date of delivery in this tracking document does not match the date of service that you 
billed.  The delivery ticket shows that it was delivered on July 25, 2022.  You have not provided any 
documentation showing when the item was dropped off at the shipping provider. There is no date in the 
documentation you provided indicating the date of actual shipment. Therefore, we decided that the Plan does 
not have to pay for code E0730 billed for date of service July 18, 2022.