Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210), periodontal 
maintenance (D4910), and comprehensive oral evaluation (D0150) provided on August 29, 2022, by an out-of-
network (OON) provider. 
 
  You asked the Plan to pay for the complete series of intraoral x-rays, periodontal maintenance, and 
comprehensive oral evaluation. You say that you were led to believe the dentist you were treated by was in-
network because they indicated that they accepted your insurance. You also say that the website you used to 
find this treating provider was not functioning correctly at the time, and you would like these services to be 
approved for coverage as a one-time exception. The Plan denied your request. The Plan says the complete 
series of intraoral x-rays and periodontal maintenance are not covered expenses under your dental plan. The 
Plan also says these dental services were received from an OON 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the complete series of intraoral x-rays 
(D0210) and periodontal maintenance (D4910) are not among those covered under this benefit. The contract 
also says 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 the complete series of intraoral x-rays (D0210), 
periodontal maintenance (D4910), and comprehensive oral evaluation (D0150) provided on August 29, 2022, 
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(s) of service 
June 14, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 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 code 83789 is not 
separately payable.  
 
 
 
 
  
 
Therefore, we decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) 
of service June 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the astigmatism correcting function of intraocular lens 
(V2787), provided on June 16, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the astigmatism correcting function of intraocular lens. You say that the service 
was medically necessary. The Plan denied your request. The Plan says service was received out-of-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 the astigmatism correcting function of intraocular 
lens (V2787), provided on June 16, 2022, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on August 19, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that your wife 
called the ambulance because she thought you were having a stroke, but you were experiencing a low blood 
sugar. You also say that they asked if you wanted to go to the hospital, and you said no. The Plan denied your 
request. The Plan says the ambulance was called, and you were not transported to the hospital. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on August 19, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
The record also shows that the trip report confirms that you refused transport and signed the trip report/refusal 
form. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with 
no transport (A0998) provided on August 19, 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. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
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 reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found documentation shows that the enrollee has functional impairments however no 
complex functional deficits are specified. Clinical documentation shows active issues have resolved thus the 
complexity of the enrollee's documented nursing, medical and rehabilitation needs would not be expected to 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the measles, mumps and rubella virus vaccine (MMR) 
(90707) provided on June 8, 2022. 
 
You asked the Plan to pay for the MMR vaccine. You say that this vaccine should be covered under your Part 
D benefits. You say that you are not sure what else you have to do. You say that you have to get baby vaccines 
due to your medical history. You also say that you have never had to pay for these before. The Plan denied 
your request. The Plan says the MMR vaccine is not covered under Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the MMR vaccine. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the MMR vaccine. 
Therefore, we decided that the Plan does not have to pay for the measles, mumps and rubella virus vaccine 
(MMR) (90707) provided on June 8, 2022.  
 
Benefits for the MMR vaccine may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the scaling in presence of generalized moderate or severe 
gingival inflammation (D4346) and six localized deliveries of antimicrobial agents (D4381 x6) provided on 
August 15, 2022. 
 
You asked the Plan to pay for the scaling and localized deliveries of antimicrobial agents. You say that you feel 
these services should be covered. The Plan denied your request. The Plan says these services are not covered 
benefits 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
scaling in presence of generalized moderate or severe gingival inflammation (D4346) and six localized 
deliveries of antimicrobial agents (D4381 x6) provided on August 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652), segmental 
appliance, trunk (E0656), segmental appliance, half leg (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the items are medically 
necessary. The Plan denied your request. The Plan says a four-week trial of conservative therapy demonstrating 
failed response to treatment with an E0650 or E0651 is required. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652), segmental appliance, trunk (E0656), segmental appliance, half leg (E0667).
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 June 8, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you would like this claim 
reprocessed and approved for payment. 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 June 8, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing this denial with 
supporting documentation. The Plan denied your request. The Plan says the denial of LTACH services is 
correct. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services that are not already available at the current 
facility. Transfer to the LTACH is not medically necessary as it would not be clinically advantageous and as 
the enrollee is not yet stable for transfer.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the home health services provided from August 1, 
2022, to August 26, 2022. 
 
You asked the Plan to reimburse you for the home health care. You say that these services should be covered. 
The Plan denied your request. The Plan says custodial care is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health care have not been met. Specifically, we find that the services at issue in this case 
are considered custodial in nature. Therefore, we decided that the Plan does not have to reimburse you for the 
home health services provided from August 1, 2022, to August 26, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the positron emission tomography (PET) scan (78816) provided on 
June 13, 2022. 
 
You asked the Plan to pay for the PET scan. You say that the service and procedure performed is supported by 
the submitted documentation. The Plan denied your request. The Plan says that charges for or in connection 
with services or supplies that are considered to be experimental or investigational are excluded from coverage 
under the enrollee's plan. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 pay for the PET scan. Our reviewer says that the 
PET scan was medically reasonable and necessary for the enrollee. Our physician reviewer found endometrial 
carcinoma is a malignant tumor involving the uterine lining. The use of PET/computed tomography (CT) is a 
covered benefit by Centers for Medicare and Medicaid Services (CMS). Our reviewer also found that this scan 
was done as a staging scan prior to planned radiation therapy and should be reimbursed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the PET scan have been met. Therefore, we decided that the Plan has to pay for 
the positron emission tomography (PET) scan (78816) provided on June 13, 2022.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cinvanti (J0185), and palonosetron HCL (J2469). 
 
You asked the Plan to pre-approve cinvanti and palonosetron HCL. You say that the requested drugs are 
medically necessary for the enrollee. The Plan denied your request. The Plan says the requested use of these 
drugs are not approved by the FDA for the enrollee's condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 cinvanti and palonosetron HCL. Our 
reviewer says that the requested drugs, cinvanti and palonosetron HCL, are not medically necessary. Our 
physician reviewer found the provided documentation does not indicate that the enrollee is receiving highly 
emetogenic chemotherapy or moderately emetogenic chemotherapy. The reviewer found that the Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. The 
reviewer also found that Medicare approved cancer drug compendia do not contain a supportive citation for the 
use of the requested drug in the enrollee's clinical situation. Therefore, the reviewer found that the requested 
drugs are not medically reasonable or 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 cinvanti and palonosetron HCL have not been met. Therefore, we decided that 
the Plan does not have to pre-approve cinvanti (J0185), and palonosetron HCL (J2469).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service August 10, 
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 August 10, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) of the heart (75571) 
provided on June 2, 2022. 
 
You asked the Plan to pay for the CT of the heart. The Plan denied your request. The Plan says Medicare does 
not cover a screening cardiac computed tomography for asymptomatic patients, for risk stratification or for 
quantitative evaluation of coronary calcium. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the CT of the heart, was requested solely for screening purposes. Medicare does 
not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for 
the computed tomography (CT) of the heart (75571) provided on June 2, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 26, 2022, to 
April 21, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the services at issue have been 
billed correctly. The Plan denied your request. The Plan says the claim has not been billed with the correct 
admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from March 26, 2022, to April 
21, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 3, 2022, to 
April 1, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the services at issue have been 
billed correctly. The Plan denied your request. The Plan says the claim has not been billed with the correct 
admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from March 3, 2022, to April 
1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the poliovirus vaccine (90713) and administration (90471) 
provided on October 3, 2022. 
 
You asked the Plan to pay for the vaccine services. You say that you needed this vaccine in preparation for a 
trip you are going on. You say that you were advised by a plan representative that this was covered under Part 
D and the copayment was $47. You say that you were not advised you needed to have this done at a pharmacy. 
You also say that you only want to pay the $47 copayment. The Plan denied your request. The Plan says this 
vaccine is not covered under Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide preventive 
immunizations. The Plan follows the same rules.  
 
There were no records provided to show that you have been injured or directly exposed to any illness related to 
the vaccine services. Therefore, we decided that the Plan does not have to pay for the poliovirus vaccine 
(90713) and administration (90471) provided on October 3, 2022.