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

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. 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. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on the medical records provided there is no documentation that you require the 
services on an inpatient basis, only in a skilled nursing facility setting. Records do not support those services in 
the home or an assisted living facility with home health care or in a long-term care facility on a part time basis 
are not appropriate 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on March 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that prior to signing up with your Plan, your agent 
said your provider was 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 dental services provided on March 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pair of glasses. 
 
You asked the Plan to pre-approve a pair of glasses. You say that you want to receive an extra pair of 
glasses/frames this year. The Plan denied your request. The Plan says this service is covered under the 
member's benefit package, but exceeds the maximum count allowed per period. 
 Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers one pair of lenses/frames and contact lenses every year. 
 
We looked at the file and the Plan's rules. The record shows that the services have already been rendered on 
January 19, 2022. Therefore, the benefit has been exhausted. Based on this information, we decided that the 
Plan's rules for coverage of a pair of glasses have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a pair of glasses.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for hospital services provided from 
December 16, 2021, to December 20, 2021. 
 
You asked the Plan to reimburse you for hospital services. The Plan denied your request. The Plan says your 
records do not show that payment was made for the services rendered upfront, which is required for coverage 
of emergencies outside of the US and its territories. The new receipt received is illegible. There is not 
documentation indicating that you have paid for the remainder of the services. 
 
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, the Medicare rules and the Plans rules. Based on this information, we decided that there 
is insufficient information in the record to determine if the rules for coverage of hospital services provided 
from December 16, 2021, to December 20, 2021 have been met. The file shows that the new receipt received is 
illegible. There is not documentation indicating that you have paid for the remainder of the services. Therefore, 
we decided that the Plan does not have to reimburse you for hospital services provided from 
December 16, 2021, to December 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service May 10, 
2021. 
 
You asked the Plan to pay for procedure code 99100. You say that these services were necessary and are 
supported in the medical record. The Plan denied your request. The Plan says they have agreed to pay for the 
other services; however, procedure code 99100 is considered bundled and 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 procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service May 10, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that this is medically necessary. The Plan denied your 
request. The Plan says step therapy requirements have 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 Euflexxa. Our reviewer says that the 
requirements for coverage of Euflexxa have not been met. Our physician reviewer found the Plan requires a 
trial of Orthovisc, Synvisc/Synvisc-One, or Monovisc before they will approve the requested drug. In this case, 
the enrollee has not tried and failed any of the required drugs. There is no documentation indicating that the 
required drugs would likely be less effective or 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 Euflexxa 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 provide additional payment for the replace missing or broken teeth - 
complete denture (each tooth) (D5520) and repair broken complete denture base, maxillary (D5512) provided 
April 1, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to provide additional payment for the dental services. You say that you feel the repairs 
should be considered one procedure. 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.  
We looked at the file and Medicare rules. The Plan provided documentation showing that you have been asked 
to pay 75% of the allowed amount for one broken tooth repair to your denture. You have also been asked to 
pay the difference between the out-of-network providers charges and the Plans payment. This cost sharing is 
a contractual obligation you agreed to pay when you enrolled in the Plan.  Though the Plan offers a dental 
benefit in excess of Medicare coverage, certain limitations apply. The record shows that your denture repair 
benefit was exhausted with the first tooth repair. The remaining tooth repair on your denture and the repair to 
the broken denture base exceed the Plans limits. Therefore, we decided that the Plan does not have to provide 
additional payment for the replace missing or broken teeth - complete denture (each tooth) (D5520) and repair 
broken complete denture base, maxillary (D5512) provided April 1, 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 the resin-based composite - three surfaces, posterior (D2393) 
provided June 22, 2022. 
 
You asked the Plan to pay for the filling. You say that you were not aware that this service is not covered under 
your benefits. 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 resin-
based composite - three surfaces, posterior (D2393) provided June 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller represented by code E2377, an 
access harness represented by code E2313, an armrest represented by code E0973, a calf pad represented by 
code E0995, and a positioning/safety belt represented by code E0978. 
 
You asked the Plan to pre-approve codes E2377, E2313, E0973, E0995, and E0978. You say that the records 
provided support the need for the items which remain in dispute. The Plan denied your request. The Plan says 
the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules say that equipment that serves the same purpose as other equipment 
already available to an enrollee is not medically necessary. Medicare rules say that providers must report 
services correctly. Providers must report services with the appropriate procedure code. 
 
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 codes E2377 and E2313. Our reviewer 
says that an expandable controller and an access harness are not considered medically reasonable and necessary 
in this case. Our physician reviewer found the provided records document that the enrollee has 3/5 to 4/5 
bilateral upper extremity strength and is modified independent with eating, dressing and grooming. This 
indicates that the enrollee has adequate upper extremity strength and function to operate the wheelchair's power 
options with their own switches. 
 
We found that codes E0973, E0995, and E0978 have a status indicator of B on the Physician Fee Schedule. 
This means that these codes are not separately payable.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes E2377, E2313, E0973, E0995, and E0978 have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an expandable controller represented by code E2377, an 
access harness represented by code E2313, an armrest represented by code E0973, a calf pad represented by 
code E0995, and a positioning/safety belt represented by code E0978.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service June 20, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says the payment for code 70450 is bundled into the 
payment for code 70470. No modifier is allowed to bypass this edit. 
 
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 70470 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 70450 billed for date of service June 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a standard manual wheelchair. 
 
You asked the Plan to pre-approve a standard manual wheelchair. You say that you have a wheelchair but you 
do not use it. The Plan denied your request. The Plan says you do not meet criteria for the requested item. 
 
The Plan must follow Medicare rules. Medicare rules say that manual wheelchairs are only covered when the 
enrollees mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or 
walker. 
 
We looked at the file and Medicare rules. Review of the file shows that you also requested a walker. The 
walker was approved by the Plan. The documentation does not support that you have mobility related deficits 
inside the home. The requested walker serves the same purpose as the requested manual wheelchair. Based on 
this information, we decided that Medicare rules for coverage of a standard manual wheelchair have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a standard manual wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral evaluation (D0140) and waive the coinsurance for a 
radiographic image (D0330) provided on June 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told you needed these procedures 
done. The Plan denied your request. The Plan says your benefit for the oral evaluation has already been 
exhausted and the proper cost share was applied to the radiographic image. 
 
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 oral evaluation was exhausted on the date of service June 7, 2022, and the Plan 
properly applied the cost share for the radiographic image done by an out-of-network provider. Therefore, we 
decided that the Plan does not have to pay for an oral evaluation (D0140) and waive the coinsurance for a 
radiographic image (D0330) provided on June 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service February 15, 
2022. 
 
You asked the Plan to pay for procedure code 99100. The Plan denied your request. The Plan says procedure 
code 99100 is considered bundled and 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 procedure code. 
 We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service February 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant surgeon services rendered on February 8, 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 the provider type is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that payment is made for an assistant at surgery when 
the procedure is authorized for an assistant and the person performing the service is a physician, physician 
assistant (PA), nurse practitioner (NP) or a clinical nurse specialist (CNS). 
 
We looked at the file and Medicare rules. Review of the record shows that the provider is not a physician, PA, 
NP, or CNS. Therefore, we decided that the Plan does not have to pay for the assistant surgeon services 
rendered on February 8, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93042 billed for date of service March 7, 
2022. 
 
You asked the Plan to pay for procedure code 93042. You say that this code was denied improperly. The Plan 
denied your request. The Plan says payment for code 93042 is bundled into payment for code 30903.  
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 93042 
is a column II code to column I code 30903. 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 93042 billed for date of service March 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the molecular pathology procedures coded as 81403, 81404, 
81405, 81406, 81407 and 81408 provided on November 24, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the pathology services. You say that you would like to appeal this claim with the 
attached medical records which prove the medical necessity of the services provided. The Plan denied your 
request. The Plan says enrollees must receive their medical services from an in-network provider with the 
exception being urgent or emergent services. Non-emergent services with non-contracted providers require 
prior authorization before services being rendered. 
 
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. Also this test is not FDA approved. 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 the molecular 
pathology procedures coded as 81403, 81404, 81405, 81406, 81407 and 81408 provided on November 24, 
2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date of service 
April 18, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service was medically necessary. The Plan denied 
your request. The Plan says this service is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by the billed code is 
considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does 
not have to pay for validity testing billed with code 83789 for date of service April 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve specialists visit to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve specialists visit. You say that it is your understanding there is no doctors within the Plan system, so you have been given a referral to an out-of-network specialist. The Plan denied your request. The Plan says the service can be provided by an in-network provider. The Plan has provided the enrollee with in-network providers.

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 specialists visit to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ultrasound, abdominal aorta, real time with image 
documentation, screening study for abdominal aortic aneurysm (code 76706) provided on June 13, 2022. 
You asked the Plan to pay for the ultrasound, abdominal aorta, real time with image documentation, screening 
study for abdominal aortic aneurysm. The Plan denied your request. The Plan says abdominal aortic aneurysm screening is a one-time screening ultrasound for people at risk. The member underwent an abdominal aorta 
study on date of service September 12, 2018. 
 
The Plan contract covers abdominal aortic aneurysm screening benefit. The Plan says abdominal aortic 
aneurysm screening is a one-time screening ultrasound for people at risk. 
 
We looked at the file, the Medicare rules and the Plans rules. The file shows that you have exceeded the 
benefit limit. Therefore, we decided that the Plan does not have to pay for an ultrasound, abdominal aorta, real 
time with image documentation, screening study for abdominal aortic aneurysm (code 76706) provided on  
June 13, 2022.