Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a CT scan of the chest. 
 
You asked the Plan to pre-approve a CT scan. You say that a CT scan is necessary to look for lung disease. The 
Plan denied your request. The Plan says that a CT scan is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 a CT scan. Our reviewer says that the 
CT scan is medically necessary. Our physician reviewer found the enrollee's last CT showed bibasilar 
interstitial lung disease and honeycombing. The positive and rising ANA titer, often associated with 
autoimmune disease, and the previous interstitial lung disease provide indications for high resolution CT 
looking for progression and typing of the interstitial lung disease. These are widely accepted criterial for high 
resolution CT and the requested exam should be approved. 
 
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 CT scan have been met. Therefore, we decided that the Plan has to pre-
approve a CT scan of the chest.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgery to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve surgery. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says it is very important to get a written referral (approval in advance) from the 
enrollees primary care physicain (PCP) before the enrollee can see a plan specialist or certain other providers 
(there are a few exceptions, listed in Section 2.2 of Chapter 3). If the enrollee doesnt have a written referral 
(approval in advance) before they get services from a specialist, the enrollee may have to pay for these services 
them self. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers.  
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
surgery to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental filling (D2391). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. 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 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 
dental filling (D2391).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
April 21, 2022, to April 25, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were told this 
would be covered. 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 $225 
copayment per day, for days 1 to 9 of inpatient hospital care.  
 
You have been asked to pay a $225 copayment per day, for days 1 to 4 of the inpatient hospital stay. You have 
been asked to pay a total of $900 ($225 copayment x 4 days = $900). This item/service falls within the 
inpatient hospital care 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 the inpatient 
hospital stay provided from April 21, 2022, to April 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on October 13, 
2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 January 11, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
October 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies. 
 
You asked the Plan to pre-approve the CGM and supplies. You say that the items should be covered as the 
enrollee disagrees with the denial. The Plan denied your request. The Plan says the items denied correctly as 
the enrollee does not meet the clinical requirements to be approved. 
 
 
 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 the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the CGM and supplies have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and 
supplies.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gammagard liquid. 
 You asked the Plan to pre-approve Gammagard liquid. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 Gammagard liquid. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the provided records do not 
indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record does not 
indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's preferred 
step one alternative. The elements of the coverage criteria are not satisfied. The requested service cannot be 
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 Gammagard liquid have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Gammagard liquid.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pulmonary rehabilitation to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the pulmonary rehab. You say that you would like the enrollee to use this 
facility due to the distance of other providers. The Plan denied your request. The Plan says network providers 
are available to render necessary care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
pulmonary rehabilitation to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve resin-based composite crown (D2391), extraction 
(D7410), maxillary partial denture (D5221) and complete maxillary denture (D5750). 
 
You asked the Plan to pre-approve crowns, extractions, and dentures. You say that this should be covered. The 
Plan denied your request. The Plan says these are not covered services. 
 
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 
resin-based composite crown (D2391), extraction (D7410), maxillary partial denture (D5221) and complete 
maxillary denture (D5750).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for paravertebral injections provided on 
October 27, 2022, to November 14, 2022, and the CT scan provided on November 16, 2022. 
 
You asked the Plan to waive the copayments for the paravertebral injections and the CT scan. You say that you 
cannot afford this. 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 $350 
copayment for copayment per day, for each outpatient procedures and services, and outpatient surgery, 
including drug administration performed in an outpatient hospital. Your contract with the Plan also clearly says 
that you must pay a $325 copayment for Medicare-covered diagnostic radiology services, including CT scans. 
 
You have been asked to pay a $350 copayment for each paravertebral injection. This item/service falls within 
the outpatient surgery, including services provided at hospital outpatient facilities benefit category. You have 
also been asked to pay $139.32, which is less than the standard $325 copayment for the CT scan. This 
item/service 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 copayments for paravertebral injections provided on October 27, 2022, to 
November 14, 2022, and the CT scan provided on November 16, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the knee replacement surgery and the 
physical therapy visit provided on August 18, 2022.  
 You asked the Plan to waive the copayments for the knee replacement surgery and the physical therapy visit. 
You say that you do not agree with the copayments. 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 $350 
copayment for in-network Medicare-covered surgery provided to you at an outpatient hospital.  
Your contract with the Plan also clearly says that you must pay a $40 copayment for each in-network 
Medicare-covered physical therapy visit.  
 
You have been asked to pay a $350 copayment for the knee replacement surgery. This item/service falls within 
the outpatient surgery and other medical services provided at hospital outpatient facilities benefit category. 
You have also been asked to pay a $40 copayment for the physical therapy visit. This item/service falls 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 copayments for 
the knee replacement surgery and the physical therapy visit provided on August 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the radiation therapy services provided 
from March 1, 2021, to April 29, 2021. 
 
You asked the Plan to waive the coinsurance for the radiation therapy. You say that you were told this would 
be paid for. 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 20% 
coinsurance for each Medicare-covered therapeutic radiology service.  
 
You have been asked to pay up to 20% coinsurance for each radiation therapy service. These items/services fall 
within the outpatient diagnostic tests and therapeutic 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 coinsurance for the radiation therapy services provided from March 1, 2021, to April 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 83520 and 87798 billed for September 21, 
2022. 
 
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 procedure codes 83520 and 87798 are not supported. 
 
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 83520 is immunoassay for analyte other than infectious 
agent antibody or infectious agent antigen; quantitative, not otherwise specified. The definition of code 87798 
is infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe 
technique, each organism. 
 
We find that CPT codes 83520 and 87798 are not supported in the medical record. Specifically, these codes are 
not otherwise specified codes and the documentation does not contain a complete description of the not 
otherwise specified codes. 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 procedure codes 
83520 and 87798 billed for September 21, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99282 billed for date of service July 27, 
2022. 
 
You asked the Plan to pay for procedure code 99282. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code 99282 is bundled into payment for code 99218.  

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 99282 
is a column II code to column I code 99218 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 99282 billed for date of service July 27, 2022.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 87500 and 87641. We 
decided that the Plan does not have to pay for the services described by procedure code(s) 87640.  
 
You asked the Plan to pay for laboratory services provided on August 1, 2022. You say that these services were 
necessary and are supported in the medical record. The Plan says that the payment for code 87640 is bundled 
into the payment for code 87641. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 87500 and 87641.  
 
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, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported. Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 87500 and 87641.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
87640. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 87640 
is a column II code to column I code 87641. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the services described by procedure code(s) 87640. 
 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95908, 95886, and 95937 billed for date of 
service August 12, 2022. 
 
You asked the Plan to pay for the billed services. You say that studies support the benefits of the services. The 
Plan denied your request. The Plan says the codes are not supported in the medical records. 
 
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 95908 is nerve conduction studies; 3-4 studies. The 
definition of code 95937 is neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, 
any 1 method. The definition of code 95886 is needle electromyography, each extremity, with related 
paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; 
complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels. 
 
We find that CPT codes 95908, 95886, and 95937 are not supported in the medical record. The records do not 
include detailed documentation of the billed codes. Based on this information, we decided that Medicare rules 
for coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure codes 95908, 95886, and 95937 billed for date of service August 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingivectomy or gingivoplasty (D4211). 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denial because you 
cannot eat properly and are in pain. 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 Plan's 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 appeal A23097109776 when the Plan 
approved D4211 for quadrant three, the duplicate request of service will remain denied. Therefore, we decided 
that the Plan does not have to pre-approve gingivectomy or gingivoplasty (D4211).