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

 
We decided that the Plan does not have to pay for an office visit provided on January 26, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-network. 
 
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 an office visit provided on January 26, 2022, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on May 
2, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told that you would not be charged for 
the services. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 3, 2021. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on May 2, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-preferred brand diabetic test strips. 
 
You asked the Plan to pre-approve non-preferred brand diabetic test strips. You say that you would like the 
Plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee has not tried and failed 
the use of the Plan's preferred brand diabetic test strips. 
 
The Plan must follow Medicare rules. Medicare rules say that Plans may limit enrollees to preferred providers 
for durable medical equipment and supplies. 
 
We looked at the file, the Plan's contract, and Medicare rules. The services at issue are diabetic test strips from 
a non-preferred brand. The services are available from the Plan's preferred brand. The medical records provided 
show no medical indication that the enrollee is unable to try the Plan's preferred brand diabetic test strips first. 
Therefore, we decided that the Plan does not have to pre-approve non-preferred brand diabetic test strips.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa (J7323). 
 
You asked the Plan to pre-approve Euflexxa. You say that the medical records provided support the necessity 
of the services in dispute. The Plan denied your request. The Plan says the criteria has been unmet the enrollee 
has not tried and failed the preferred step therapy (multi-injection) device(s): Orthovisc OR Supartz FX. 
 
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 Euflexxa. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the Plan requires a trial of drug Orthovisc OR Supartz FX before they will approve the 
requested drug. The case file does not contain documentation of trial and failure of Orthovisc or Supartz FX. 
The documentation does not support that Orthovisc or Supartz FX would likely be less effective, and/or would 
likely have adverse effects for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa (J7323).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), intraoral periapical 
radiographic images (D0220, D0230), bitewing radiographic images (D0272), and periodontal scaling and root 
planing (D4341 x2) provided on September 25, 2020. 
 
You asked the Plan to pay for the dental services. You say that you want the Plan to pay for the services The 
Plan denied your request. The Plan says the claim was not received until March 29, 2022. Part C claims must 
be mailed within 12 months of the date of service. 
 
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 dental services was not filed until March 29, 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 a limited oral evaluation (D0140), intraoral periapical radiographic images 
(D0220, D0230), bitewing radiographic images (D0272), and periodontal scaling and root planing (D4341 x2) 
provided on September 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), prophylaxis 
(D1110), and an intraoral x-ray series (D0210) provided on March 30, 2022. 
 
You asked the Plan to pay for the dental services. You say that the dentist is in-network. The Plan denied your 
request. The Plan says the dental services were received from an out-of-network provider and are not covered 
by your supplemental 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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a comprehensive oral evaluation (D0150), prophylaxis (D1110), and an intraoral x-ray series 
(D0210) provided on March 30, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has knee osteoarthritis. She 
has not tried and failed the Plan's required drugs; Orthovisc, Supartz FX, Durolane, Monovisc, or Synvisc-One. 
The records do not show that the required drugs would be contraindicated or less effective; therefore, Euflexxa 
is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Euflexxa.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for crown - porcelain fused to high noble metal (D2750) 
provided on January 10, 2022. 
 
You asked the Plan to pay for crown - porcelain fused to high noble metal (D2750). You say that you were 
advised that you had dental coverage for crowns. 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested crown is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for crown - porcelain 
fused to high noble metal (D2750) provided on January 10, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the crown porcelain/ceramic (D2740) and the nitrous oxide (D9230) 
provided on December 8, 2021. 
 
You asked the Plan to pay for the dental services. You say that you paid for these services and have not 
received reimbursement. The Plan denied your request. The Plan says that you have already received the 
maximum amount of coverage allowed for this type of service. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not include documentation to prove their denial. Without this 
documentation we cannot determine that any reimbursement was paid to you, or your balance for non-
Medicare covered dental services allowance at the time of service. Therefore, we decided that the Plan has to 
pay for the crown porcelain/ceramic (D2740) and the nitrous oxide (D9230) provided on December 8, 2021.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services (D0001, D0330, D6190, D6010) provided 
from October 13, 2021 to March 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the charges. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
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, 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 dental 
services (D0001, D0330, D6190, D6010) provided from October 13, 2021 to March 18, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 37187, 37252, 75820 and 75825 billed for 
date for service August 30, 2021. 
 
You asked the Plan to pay for procedure codes 37187, 37252, 75820 and 75825. You say that the enrollee 
received multiple services on the date in question, and these services were reported correctly. The Plan 
denied your request. The Plan says the payment for codes 75820 and 75825 is usually bundled into the payment for 
code 37248. Although codes 75820 and 75825 were billed with modifiers to indicate separate payment, the 
medical records provided do not support that the 59 modifier was used correctly for these services. In addition, 
codes 37187 and 37252 are not supported in the medical records provided. 
 
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 37187 is percutaneous transluminal mechanical 
thrombectomy, veins(s), including intraprocedural pharmacological thrombolytic injections and fluoroscopic 
guidance. The CPT Code Manual definition of code 37252 is intravascular ultrasound (noncoronary vessel) 
during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and 
interpretation; initial noncoronary vessel (List separately in addition to code for primary procedure). 
 
We have also confirmed that code 75820 is a column II code to column I code 37248, and that code 75825 is a 
column II code to column I code 37248. However, codes 75820 and 75825 were each billed with a modifier to 
bypass the edit. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for codes 37187, 37252, 75820 and 75825. Our reviewer says 
that these services are not supported as billed. Our reviewer found that the procedure report does not include 
documentation of a pharmacological thrombolytic injection. The documentation describes an infusion, and 
therefore CPT code 37187 cannot be verified. In addition, documentation of an intravascular ultrasound 
(noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention was not found in procedure 
report. Therefore, CPT code 37252 also cannot be verified with the documentation provided. The procedure 
report does describe intervention procedures, but in this case, they would be included in the primary procedure 
code 37248. Modifier 59 is not supported for either code, and therefore separate payment for these services is 
not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 37187, 37252, 75820 and 75825 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 37187, 37252, 75820 and 75825 billed for 
date for service August 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 5, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-network. 
 
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 an office visit provided on January 5, 2022, by an 
out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy (PT) services provided on 
March 23, 2022. 
 
You asked the Plan to waive the copayment for the PT services. You say that you were not aware that you 
would owe $30 for each visit. The Plan denied your request. The Plan says you have been charged the correct 
cost sharing amount. 
 
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 $30 
copayment for each physical therapy visit.  
 You have been asked to pay a $30 copayment for the PT services. The PT services fall within the Outpatient 
Rehabilitation 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 physical 
therapy (PT) services provided on March 23, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the massage therapy services provided between October 10, 2021, and 
December 19, 2021, up to the $250 annual allowance. 
 
You asked the Plan to pay for the massage therapy services. You say that you were told you could have an 
extension. The Plan denied your request. The Plan says that your request for reimbursement was not submitted 
within 60 days of the end of the 2021 plan year. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, we did not see where the contract says enrollees must submit a 
reimbursement request within 60 days. The Plan has not provided any other rationale for their denial. 
Therefore, we decided that the Plan has to pay for the massage therapy services provided between October 10, 
2021, and December 19, 2021, up to the $250 annual allowance. 
  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the reline complete lower denture (D5751) provided on  
April 19, 2022. 
 
You asked the Plan to pay for the dental item. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says your benefit for the service provided 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 service provided was exhausted on date of service April 19, 2022. Specifically, the 
Plan contract covers one reline complete denture per calendar year. On this day, you received two of these 
dental items. The Plan issued payment previously for one reline complete upper denture. Therefore, you have 
exhausted the allowable benefit for this item. Therefore, we decided that the Plan does not have to pay for the 
reline complete lower denture (D5751) provided on April 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient psychiatric care provided from April 20, 2021, 
through May 12, 2021. 
 
You asked the Plan to pay for these services. You say that the inpatient psychiatric care provided was 
medically necessary for the enrollee. The Plan denied your request. The Plan says the inpatient psychiatric care 
provided was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 pay for these services. Our reviewer says that the 
inpatient psychiatric care provided was not medically necessary. Our physician reviewer found that this 
enrollee was involuntarily admitted to the acute inpatient psychiatric hospital on April 5, 2021 with Major 
Neurocognitive Disorder, Unspecified with Behavioral Disturbance, Major disorder, Recurrent, Severe with 
Psychotic Features and Personality Disorder Unspecified. Based upon the review of the records provided, it 
was not expected that this enrollee would improve in a reasonable period of time beyond the date in question as 
he was not showing any dangerousness to self or others, auditory or visual hallucinations, and was without 
aggressive behaviors, while not showing any acute threats of safety. It did not appear medically necessary and 
reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care 
beyond the date in question as he did not have any suicidal or homicidal thoughts, auditory or visual 
hallucinations or abnormal behaviors. The health plans denial of continued inpatient psychiatric services 
appears appropriate. It did not appear that active treatment was taking place beyond the date in question. It did 
not appear that the services for the dates in question were reasonably expected or medically necessary to 
improve the enrollees condition or were for the purpose of a diagnosis. Based upon the review of the records 
provided, this enrollee does not meet the criteria for coverage of acute inpatient mental health treatment beyond 
the date in question of April 20, 2021 forward and could have been treated in a lesser restrictive setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the inpatient psychiatric care provided from April 20, 2021, through May 12, 2021.