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

 
We decided that the Plan does not have to pay for therapy technique (97530), mechanical traction (97012), and 
extra-spinal manipulation (98943) provided on April 13, 2022. 
 
You asked the Plan to pay for the therapy technique, traction, and manipulation. You say that you were given 
incorrect information about your chiropractor visits. The Plan denied your request. The Plan says you reached 
your maximum enhanced chiropractic services on your March 28, 2022, visit. 
 
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 Plan offers a chiropractic benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  We looked at your request, the file, and rules. Based on this information we have determined that criteria for 
payment have not been met. Though the Plan offers a chiropractic 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 28, 2022. Therefore, we decided that the Plan does not have to pay for therapy technique 
(97530), mechanical traction (97012), and extra-spinal manipulation (98943) provided on April 13, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aduhelm. 
 
You asked the Plan to pre-approve Aduhelm. You say that this drug is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says the criteria for coverage have not been satisfied. 
 
The Plan must follow Medicare rules. Medicare rules say that Aduhelm provided outside of an approved trial 
or study is nationally non-covered. 
 
We looked at the file and Medicare rules. In this case, the case record does not indicate that the enrollee is 
participating in an approved trial or study. Based on this information, we decided that Medicare rules for 
coverage of Aduhelm have not been met. Therefore, we decided that the Plan does not have to pre-approve 
Aduhelm.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator, any type, used with non-invasive 
interface, (e.g., mask, chest shell) (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that you are appealing the denial of the prior 
authorization that was denied four weeks ago for E0466 non-invasive home ventilator to be used for the 
treatment of COPD. The Plan denied your request. The Plan says the enrollee does not meet the necessary 
medical requirements. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this enrollee has COPD, heart failure with reduced ejection fraction, with elevation of partial pressure of carbon dioxide (CO2) suggestive of acute respiratory failure (reduced pH), that may have been due 
in part to congestive heart failure. There is no documentation of chronic CO2 retention on an arterial blood 
gases done while stable as an outpatient. If the enrollee does have chronic CO2 retention, they may benefit 
from bilevel positive airway pressure (BiPAP) with average volume-assured pressure support during sleep. But 
Medicare does not pay for a home ventilator when used as BiPAP. A home ventilator is 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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell) 
(E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic hearing exam provided on April 
22, 2022. 
 
You asked the Plan to waive the copayment for diagnostic hearing exam. You say that this should be covered. 
The Plan denied your request. The Plan says the copayment applied 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 $45 
copayment for a Medicare-covered diagnostic hearing exam.  
 
You have been asked to pay $45 copayment for diagnostic hearing exam. Diagnostic hearing exam falls within 
the Hearing 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 diagnostic hearing 
exam provided on April 22, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for diagnostic imaging and an injection 
provided on May 31, 2022. 
 
You asked the Plan to waive the cost share for diagnostic imaging and an injection. You say that you were 
never informed you would have to pay anything. The Plan denied your request. The Plan says the cost share 
applied 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 $300 
copayment for Medicare-covered diagnostic radiology services and 20% of the total cost for Part B covered 
drugs.  
 
 You have been asked to pay $300 copayment for diagnostic imaging. You have been asked to pay $49.20 
which is 20% of the total cost for the injection. The total cost for the injection was $246 (20% x $246 = 
$49.20). The total you have been asked to pay is $349.20. Diagnostic imaging falls within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies benefit category. The injection falls within the 
Medicare Part B Prescription Drugs 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 cost share for 
diagnostic imaging and an injection provided on May 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial maxillary denture (D5225) and a partial 
mandibular denture (D5226), provided by a participating provider. 
 
You asked the Plan to pre-approve the dental services. You say that you would like approval for these dentures. 
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 December 22, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a partial maxillary denture (D5225) and a 
partial mandibular denture (D5226), provided by a participating provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70544 billed for date of service April 3, 
2022. 
 You asked the Plan to pay for procedure code 70544. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70544 is bundled into payment for 
code 70551. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70544 
is a column II code to column I code 70551. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70544 billed for date of service April 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on August 19, 2021. 
 
You asked the Plan to pay for laboratory services. The Plan denied your request. The Plan says the provider has 
not submitted the provider/progress notes that are needed in order to determine the clinical utility of the testing. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
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 laboratory services provided on 
August 19, 2021 have been met. Therefore, we decided that the Plan does not have to pay for laboratory 
services provided on August 19, 2021.
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. The Plan denied your request. The Plan says your needs can safely 
be met at a lower level of care. 
 
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 physician reviewer found 
that you were admitted to the acute care hospital for back pain after thoracolumbar surgery. Your medical 
problems are stable. The complexity of your nursing, medical and rehabilitation needs does not require an acute 
hospital inpatient stay 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76700 billed for date of service April 19, 
2022. 
 
You asked the Plan to pay for procedure code 76700. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76700 is bundled into payment for 
code 93976. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76700 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76700 billed for date of service April 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation (D4921) provided by a participating 
provider. 
 
You asked the Plan to pre-approve gingival irrigation. You say that these services were medically necessary. 
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 
gingival irrigation (D4921) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve biological materials (D3431) provided by a participating 
provider. 
 
You asked the Plan to pre-approve biological materials. You say that these services are medically necessary. 
The Plan denied your request. The Plan says D3431 has 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 pre-approve 
biological materials (D3431) provided by a participating provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 11, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. 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 April 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 23, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. 
 The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory 
testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
February 23, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on April 
23, 2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you are on a fixed income 
and cannot afford this payment. The Plan denied your request. The Plan says you were charged this cost 
sharing 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 $325 
copayment for each ambulance trip. You had one ambulance trip(s). The Plan charged you $325 for these 
services. 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 the ambulance services provided on April 23, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ophthalmic biometry provided on April 11, 
2022. 
 
You asked the Plan to waive the copayment for ophthalmic biometry. You say that you should not be 
responsible for this copayment because this was related to your cataract surgery. The Plan denied your request. 
The Plan says the cost share was applied 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 $20 for 
Medicare-covered outpatient diagnostic tests.  
 
You have been asked to pay $20 for ophthalmic biometry. Ophthalmic biometry 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 ophthalmic biometry provided on April 11, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76700 billed for date of service April 24, 
2022. 
 You asked the Plan to pay for procedure code 76700. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76700 is bundled into payment for 
code 93976. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76700 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76700 billed for date of service April 24, 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. The Plan denied your request. The Plan says you do not require an 
interdisciplinary approach to rehabilitation care. 
 
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 physician reviewer found 
that you were admitted to the acute hospital for concern for infection at the surgical site of recent 
thoracolumbar surgery. Your medical problems are stable. The complexity of your nursing, medical and 
rehabilitation needs does not require an acute hospital inpatient stay 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair with power tilt option and a power 
seat elevation option. 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the enrollee needs the 
requested wheelchair due to a pressure ulcer of the buttocks. The Plan denied your request. The Plan says 
Medicare does not consider a facility or distinct part of a facility your home when it provides medical or 
nursing care. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that a power wheelchair and accessories is being requested for use in a SNF or hospital. 
Therefore, we decided that the Plan does not have to pre-approve a power wheelchair with power tilt option 
and a power seat elevation option.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve minimally invasive lumbar decompression (0275T). 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that you are not noted to be enrolled in a CED-approved clinical study 
or a CMS-approved randomized controlled trial. 
 
The Plan must follow Medicare rules. Medicare rules say that Percutaneous Image-Guided Lumbar 
Decompression (PILD) will be covered by Medicare when provided in a clinical study under section 
1862(a)(1)(E) of the Social Security Act (the Act) through Coverage with Evidence Development (CED). 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the minimally invasive lumbar decompression have not been met. Specifically, you are not 
enrolled in a clinical study. Therefore, we decided that the Plan does not have to pre-approve minimally 
invasive lumbar decompression (0275T).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a crown (D2740) and a core build-up 
(D2740), provided by a participating provider on March 14, 2022. 
 
You asked the Plan to waive the coinsurance for a crown and a core build-up. You say that you were not 
reimbursed the full amount. The Plan denied your request. The Plan says the correct coinsurance has been 
applied. 
 
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 50% 
coinsurance for dental services (additional)/out-of-network.  
 
You have been asked to pay a 50% coinsurance of the allowed amount for a crown and a core build-up. The 
total allowed amount is $750. The total amount you are being asked to pay is $375 ($750 x 50% = $375). A 
crown and a core build-up fall within the dental services (additional)/out-of-network benefit category. These 
services were provided by an out-of-network provider. 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 a 
crown (D2740) and a core build-up (D2740), provided by an out-of-network provider on March 14, 2022.