Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trivisc. 
 
You asked the Plan to pre-approve Trivisc. You say that the injections are recommended after other 
medications were tried and did not help. You say that the requested injections will help with pain relief and 
mobility. The Plan denied your request. The Plan says the enrollee has not responded adequately to 
conservative therapy which may include physical therapy or pharmacotherapy, or injection of intra-articular 
steroids and such therapy has not resulted in functional improvement after at least 3 months. There is no evidence that the enrollee is unable to tolerate conservative therapy because of adverse side effects. 
The enrollee does not have a history of failure, contraindication, or intolerance to the formulary alternatives. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Trivisc. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the enrollee has a history of unilateral 
primary osteoarthritis. The enrollee's provider has requested viscosupplementation therapy with Trivisc. She 
has not trialed viscosupplemental treatments such as Synvisc, Durolane, and Gelsyn-3.  Step therapy, as 
outlined by the plan, requires that these be trialed first. The documentation does not outline contraindications or 
reasons these medications were not considered or that the plan's required drugs would likely be less effective 
and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Trivisc have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Trivisc.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on February 
17, 2022. 
 
You asked the Plan to pay for the periodontal maintenance. You say that this was not a periodontal 
maintenance appointment. You also say that it was just a regular cleaning. The Plan denied your request. The 
Plan says this service is not a covered expense under your dental 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 
periodontal maintenance (D4910) provided on February 17, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Myocardial Perfusion Imaging (78452). 
 
You asked the Plan to pre-approve the Myocardial Perfusion Imaging. You say that the service is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that tests performed when the results would not be 
anticipated to influence medical management decisions will be denied as not 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 Myocardial Perfusion Imaging. Our 
reviewer says that this service is not medically necessary. Our physician reviewer found there is insufficient 
documentation to support the medical necessity for the requested cardiac stress testing in this patients clinical 
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 the Myocardial Perfusion Imaging have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Myocardial Perfusion Imaging (78452).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist visit on January 14, 2022. 
 
You asked the Plan to waive the copayment for specialist visit. You say that you called the plan, and you were 
told your appointment would be covered in full. The Plan denied your request. The Plan says coinsurance is 
correct. 
 
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 $25 
copayment for each Medicare-covered and non-Medicare-covered in-network care.  
 
  You have been asked to pay $25 copayment for the specialist visit. Specialists visit falls within the Podiatry 
services 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 specialist visit on January 
14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and panoramic 
x-ray (D0330) provided on January 28, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation and panoramic x-ray. You say that the office 
was charging double. The Plan denied your request. The Plan says these services exceed the maximum allowed 
per period. 
 
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, comprehensive oral evaluation 
(D0150) and panoramic x-ray (D0330) are each limited to one procedure every three plan years. The record 
shows that you received a comprehensive oral evaluation (D0150) on November 11, 2021 and you received a 
panoramic x-ray (D0330) on December 16, 2021, and your comprehensive oral evaluation (D0150) and 
panoramic x-ray (D0330) benefits have been exhausted. Therefore, we decided that the Plan does not have to 
pay for the comprehensive oral evaluation (D0150) and panoramic x-ray (D0330) provided on January 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140), periapical x-ray 
(D0220), and extraction (D7140) provided on February 15, 2022, by an out of network dentist. 
 
You asked the Plan to pay for the dental services. You say that during your phone call with a plan 
representative you were not advised you needed to use a certain dentist. You say that you received a bill in the 
mail. You also say that you will change insurance if you need to fight over this. The Plan denied your request. 
The Plan says dental services received out of network are not covered. 
 
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 and the services are listed as covered, 
dental services received out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), periapical x-ray (D0220), and 
extraction (D7140) provided on February 15, 2022, by an out of network dentist.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services with the presence of an 
independent trained observer (99152) billed for date of service August 10, 2021. 
 
You asked the Plan to pay for moderate sedation services. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met 
because the available records do not support the service billed. 
 
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, the CPT Code Manual definition of code 99152 is "Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older." 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, the provided documentation 
does not support the presence of an independent trained observer. Based on this information, we decided that 
Medicare rules for coverage of moderate sedation services have not been met. Therefore, the Plan does not 
have to pay for moderate sedation services with the presence of an independent trained observer (99152) billed 
for date of service August 10, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for Computed tomography, heart, without contrast material, with 
quantitative evaluation of coronary calcium (CCTA) (75571). 
 
You asked the Plan to pay for the CCTA. You say that the service is medically necessary. The Plan denied your 
request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
We 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 for the CCTA. Our reviewer says that the service is not 
medically necessary. Our physician reviewer found that aside from the report of the CT coronary calcium 
screening test, no medical records showing the medical necessity of the test were included. 
 
The test at issue in this appeal, the CCTA, was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for 
Computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium 
(CCTA) (75571).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fixed partial denture sectioning (D9120) provided August 
11, 2021. 
 
You asked the Plan to pay for the fixed partial denture sectioning. You say that you would like this service 
covered. The Plan denied your request. The Plan says this service is not covered under your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the fixed 
partial denture sectioning (D9120) provided August 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endodontic therapy, premolar tooth (excluding final 
restoration) (D3320) for tooth 20 provided May 21, 2021. 
 
You asked the Plan to pay for the root canal. You say that you believe there has been an error in funding 
calculations in 2022. The Plan denied your request. The Plan says you have exceeded the frequency limit for 
this service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the root canal 
once per tooth per lifetime. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a root canal for tooth 
20 was previously covered on October 8, 2020. Based on this information, we decided that the Plan's frequency limit for coverage of the root canal for tooth 20 has been exceeded. Therefore, we decided that the Plan does 
not have to pay for the endodontic therapy, premolar tooth (excluding final restoration) (D3320) for tooth 20 
provided May 21, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from 
October 7, 2019, through November 5, 2019. 
 
You asked the Plan to pay for the SNF services. You say that it is felt that Medicare coverage criteria were met 
for these dates. The Plan denied your request. The Plan says the enrollee elected hospice on September 28, 
2019. This means that Original Medicare is responsible for this claim. 
 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 skilled nursing facility (SNF) services provided from 
October 7, 2019, through November 5, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services and computed tomography 
(CT) scan of the head/brain rendered on December 29, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not 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. 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. We find that CPT 
code 99053 has a status indicator of B on the Physician Fee Schedule. This means that CPT code 99053 is not 
separately payable. 
 
Therefore, we decided that the Plan does not have to pay for the moderate sedation services and computed 
tomography (CT) scan of the head/brain rendered on December 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) and an 
extraction (D7210) to be performed by an oral surgeon. 
 
You asked the Plan to pre-approve a comprehensive oral evaluation and an extraction to be performed by an 
oral surgeon. You say that the requested services are medically necessary. The Plan denied your request. The 
Plan says the services at issue are not covered unless they are performed by a participating general dentist. 
Dental services performed by an oral surgeon are not covered. 
 
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.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a comprehensive oral evaluation and an extraction to be performed by an oral surgeon have not 
been met. Specifically, the services at issue are not covered unless they are performed by a participating 
general dentist. Therefore, we decided that the Plan does not have to pre-approve a comprehensive oral 
evaluation (D0150) and an extraction (D7210) to be performed by an oral surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a microprocessor control feature, addition to upper limb 
prosthetic terminal device (L6882) and an upper extremity prosthesis, Taska Hand (L7499). 
 
You asked the Plan to pre-approve a microprocessor control feature and an upper extremity prosthesis. You say 
that you did not receive any prosthetics from any provider. You also say that partial approval was not a 
practical solution for features that were not approved. The Plan denied your request. The Plan says the vendor 
is miscoding L7499 and L6882. 
 
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 L6882 and L7499 are not supported. Specifically, both codes are unbundled and 
incorrectly coded.  The codes cannot be used with a miscellaneous code, approved, or covered separately. 
Based on this information, we decided that Medicare rules for coverage of a microprocessor control feature and 
an upper extremity prosthesis have not been met. Therefore, we decided that the Plan does not have to pre-
approve a microprocessor control feature, addition to upper limb prosthetic terminal device (L6882) and an 
upper extremity prosthesis, Taska Hand (L7499).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion/specialty drug administration, per visit, 
(99601) provided on June 19, 2020. 
 
You asked the Plan to pay for the infusion service. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the service is not covered. 
 
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 99601 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code 99601 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the infusion service have not been met. Therefore, we decided that the Plan does not have to pay 
for the home infusion/specialty drug administration, per visit, (99601) provided on June 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the four two dimensional (2D) oral/facial photographic 
images (D0350 x4) provided on January 26, 2022. 
 
You asked the Plan to pay for the 2D oral/facial photographic images. You say that you believe the payment 
should not have been denied for these services. The Plan denied your request. The Plan says this service is not 
a covered benefit under your dental 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 four 
two dimensional (2D) oral/facial photographic images (D0350 x4) provided on January 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental implant services provided by an out-of-network 
provider on January 6, 2022. 
 
You asked the Plan to pay for dental implants. You say that you believe that these services should be covered. 
The Plan denied your request. The Plan says services provided out-of-network are not covered. 
 
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. The Plan covers covered 
dental benefits when the services are provided by a participating provider.  
 
We looked at the file and Medicare rules. The rendering dentist is out-of-network. Based on this information, 
we decided that the Plan's rules for coverage of dental implants have not been met. Therefore, we decided that 
the Plan does not have to pay for dental implant services provided by an out-of-network provider on January 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral imaging (D0220 and D0230) provided by an out-of-
network provider on January 7, 2022. 
 
You asked the Plan to pay for intraoral imaging. You say that you were told that all x-rays were covered under 
your plan. The Plan denied your request. The Plan says the x-rays provided have been correctly denied. 
 
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 intraoral 
imaging (D0220 and D0230) provided by an out-of-network provider on January 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of aquatic therapy. 
 
You asked the Plan to pre-approve continuation of aquatic therapy. You say that you need aquatic therapy to 
deal with pain. You say you cannot do regular physical therapy because it increases you pain levels, and you 
have a number of chronic pain conditions, and the state of your joints does not allow you to carry out exercises 
on land. You say that the heat of the water and the gentle resistance provided by the aquatic therapy help to 
reduce you pain levels. The Plan denied your request. The Plan says we agree that you need to continue to do 
the therapy exercises you were taught to maintain function as maintenance, but it is no longer so complex that 
it requires a therapist. Fortunately, there are multiple community pools you can visit to do the exercises. 
Community pools usually offer a reduced fee for seniors, and often have instructor led aquatic exercise 
programs. 
 
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 continuation of aquatic therapy. Our 
reviewer says that the requested continuation of aquatic therapy is not considered medically reasonable and 
necessary in this case. Our physician reviewer found that you have 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. The additional therapy services are not an appropriate duration and frequency for 
treatment of your 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 continuation of aquatic therapy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve continuation of aquatic therapy.