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

 
We decided that the Plan does not have to pay for the pulp cap (D3120) or pay more for the resin-based 
composite (D2393) provided on January 13, 2022. 
 
You asked the Plan to pay for the pulp cap and to pay more for the resin-based composite. You say that this 
visit should be processed under your medical insurance, not dental. The Plan denied your request. The Plan 
says the pulp cap is not a covered expense under your dental plan. The Plan also says that you did not contact 
the Plan prior to the date of service to verify benefits and provider eligibility. 
 
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, pulp cap (D3120) is not among those 
covered under this benefit. The contract clearly states that you are responsible for a $25 copayment for resin-
based composites that are rendered by an in-network provider. Therefore, we decided that the Plan does not 
have to pay for the pulp cap (D3120) or pay more for the resin-based composite (D2393) provided on January 
13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on January 21, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that the patient does not go to your laboratory, so 
he/she is not using out-of-network benefits as his/her participating doctor sends you the specimens to process. 
The Plan denied your request. The Plan says this provider is not a network provider with the Plan, and they 
have also determined that these services are not urgent or emergent, nor were they approved in advance. 
 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 laboratory services provided on January 21, 2022, 
by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an abutment supported porcelain/ceramic crown 
(D6058), and a custom fabricated abutment (D6057) provided by an out-of-network provider. 
 
You asked the Plan to pre-approve an abutment supported porcelain/ceramic crown and a custom fabricated 
abutment. You say that you would like the Plan to approve these services because they are medically necessary. 
The Plan denied your request. The Plan says the requested dental benefits are not covered. 
 
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 an abutment supported porcelain/ceramic crown (D6058), and a custom fabricated abutment (D6057) provided by 
an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for oxygen equipment provided on December 
17, 2021, January 17, 2022, and February 17, 2022. 
 
You asked the Plan to waive the copayment for oxygen equipment. You say that you think your insurance 
should cover this because you have no income and no one to help pay this bill. The Plan denied your request. 
The Plan says coinsurance is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance in-network.  
 
  You have been asked to pay $86.25, which is 20% of the allowed amount for oxygen equipment. The allowed 
amount is $431.16 (20% x $431.16/3 months = $86.25). The oxygen equipment falls within the Durable 
medical equipment (DME) and related supplies benefit category. This means that you have been asked to pay 
the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for oxygen equipment provided on December 17, 2021, January 17, 2022, and February 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone graft (D6104), provided by a participating 
provider. 
 
You asked the Plan to pre-approve bone graft. You say that you would like the Plan to approve these services. 
The Plan denied your request. The Plan says the requested dental service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
bone graft (D6104), provided by a participating provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the initial hospital care rendered on June 22, 2021. 
 
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 that the services are not separately payable. 
 
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 states that billed code 99221 is not payable because it is inclusive to 
code 36620; however, there are no National Correct Coding Initiative (NCCI) procedure-to-procedure (PTP) 
edits for this code pair. The Plan has not provided any Medicare rules or documentation to support that code 
99221 is not payable as billed. Therefore, we decided that the Plan has to pay for the initial hospital care 
rendered on June 22, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for orthotic(s) management and training provided on  
June 18, 2021. 
 
You asked the Plan to pay for orthotic(s) management and training. The Plan denied your request. The Plan 
says prior authorization was not obtained by the provider or facility. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for orthotic(s) management and training provided on June 18, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is 
medically necessary. The Plan denied your request. The Plan says the requested continued SNF care does not 
meet criteria. 
 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 continued SNF care. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found you received oral medications, had 
stable vital signs and your lungs were clear. You do not require skilled nursing or therapy services on a daily 
basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled 
nursing facility 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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
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 does not meet 
criteria. 
 
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 the enrollee is medically stable and does not need PM&R physician close supervision 
3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic 
medical conditions. At the current functional level, the enrollee does not require 3 hours a day five days a week 
of IRF therapies with interdisciplinary management. The enrollee's rehab needs can be provided in an alternate 
and low intensity setting such as in a skilled nursing facility. 
 
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 outpatient hospital services provided on October 14, 
2021. 
 
You asked the Plan to pay for the outpatient hospital services. You say that this should be paid. The Plan 
denied your request. The Plan says this was not billed correctly as a modifier is missing. 
 
The Plan must follow Medicare rules. Medicare rules say that the I/OCE edits all outpatient hospital claims. 
OCE edit 21 is applied when a procedure (type T or S) is billed on the same day as an E&M service (type V) 
without modifier -25 being added to the E&M service.  
 
We looked at the file and Medicare rules. Code G0463 is type V, an E&M service. It was billed on the same 
date as 88305 which is type S. Modifier -25 was not appended as required. Based on this information, we 
decided that Medicare rules for coverage of the outpatient hospital services have not been met. Therefore, we 
decided that the Plan does not have to pay for the outpatient hospital services provided on October 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral (right and left side) L3-L4, L4-L5 medial 
branch block (MBB) injection (CPT code 64493). 
 
You asked the Plan to pre-approve the services. You say that the service is necessary. The Plan denied your 
request. The Plan says the medical records show that the enrollee's back pain radiates into the enrollee's 
buttocks and posterior aspect of their upper legs, and their imaging reports do not support the policy criteria. 
 
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 services. Our physician reviewer 
found the enrollee has several probable pain generators with disc disease and spinal instability and therefore, 
the criteria are not met. The request is deemed 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bilateral (right and left side) L3-L4, L4-L5 medial branch block (MBB) injection (CPT 
code 64493).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for image-guided fluid drainage by catheter (49406) provided on 
December 14, 2021. 
 
You asked the Plan to pay for image-guided fluid drainage by catheter. You say that you have provided records 
to support the service billed. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not allow separate payment for an 
additional procedure(s) with a global surgery fee period if furnished during the postoperative period of a prior 
procedure and if billed without modifier -58, -78, or -79.. 
 We looked at the file and Medicare rules. In this case, the record shows that the service at issue was furnished 
during the postoperative period of a prior procedure. The service at issue was billed without the appropriate 
modifier. Based on this information, we decided that Medicare rules for coverage of image-guided fluid 
drainage by catheter have not been met. Therefore, we decided that the Plan does not have to pay for image-
guided fluid drainage by catheter (49406) provided on December 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. 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 does not meet 
criteria. 
 
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 the enrollee is medically stable and does not need PM&R physician close supervision 
3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic 
medical conditions. The enrollee does not require 3 hours a day five days a week of IRF therapies with 
interdisciplinary management. The enrollee's rehab needs can be provided in an alternate and low intensity 
setting such as in a skilled nursing facility. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dupixent. 
 
You asked the Plan to pre-approve Dupixent. You say that the records provided support the need for the drug in 
dispute. The Plan denied your request. The Plan says the requested medication does not fall under Part B 
coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Dupixent.  
 Benefits for Dupixent 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: Surgery
Decision: Favorable

 
We decided that the Plan does not have to pre-approve Sinuva implants for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that the enrollee's symptoms are affecting her 
lifestyle and work ability. The Plan denied your request. The Plan says that services determined to be 
investigational are not covered by the Health Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 these services. Our reviewer says that 
the requested services are considered medically reasonable and necessary in this case. There is sufficient peer-
reviewed evidence to support the use of mometasone furoate sinus implant for recurrent sinonasal polyposis in 
patients who are higher risk with revision surgery. Our physician reviewer found that the enrollee's condition 
meets criteria for coverage of these services. 
 
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 been met. 
 
 
 
 
  
 Therefore, we decided that the Plan does not have to pre-approve Sinuva implants for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kyphoplasty (22514) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that the member has continued severe back pain and 
inability to perform activities of daily living. The Plan denied your request. The Plan says that this is not 
indicated because the vertebral body fracture is associated with widened pedicles or retropulsion of bone as in a 
burst fracture. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Imaging shows 
posterior L1 retropulsion which is a contraindication to kyphoplasty. Our physician reviewer found that the 
enrollee's condition does not meet Medicare criteria for these services. 
 
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 Kyphoplasty (22514) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network 
(OON) provider on June 16, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on June 16, 
2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hydrocodone-acetaminophen. 
 
You asked the Plan to pre-approve Hydrocodone-acetaminophen. You say that the medical records provided 
support the need for the requested drug. The Plan denied your request. The Plan says the requested medication 
does not fall under Part B coverage. The Plan says that the enrollee does not have pharmacy benefits 
administered under this contract. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Hydrocodone-
acetaminophen.  
 Benefits for Hydrocodone-acetaminophen may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.