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

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on May 
24, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you did not ask for 
the ambulance transport. The Plan denied your request. The Plan says you have been charged the correct cost 
sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for each ambulance service.  
 
You have been asked to pay a $250 copayment for the ambulance transportation. The ambulance transportation 
falls within the Ambulance Services benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
ambulance transportation provided on May 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Nerve conduction studies; 11-12 studies (95912) 
provided on August 26, 2021. 
 
You asked the Plan to pay for code 95912. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the medical records do not support the billing of code 
95912. 
 
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 95912 is Nerve conduction studies; 11-12 studies.  
We find that CPT code 95912 is not supported in the medical record. Specifically, the records provided 
document less than eleven studies were performed. Based on this information, we decided that Medicare rules 
for coverage of code 95912 have not been met. Therefore, we decided that the Plan does not have to pay for the 
Nerve conduction studies; 11-12 studies (95912) provided on August 26, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve guided tissue regeneration on tooth #4, 5, and 6 (D4266), 
endosteal implant on tooth #4 and 6 (D6010), custom fabricated abutment on tooth #4 (D6057), implant 
supported crown on tooth #4 (D6065), and a bone graft on tooth #4 (D6104). 
 
You asked the Plan to pre-approve the dental services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the requested services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide a copy of the current Evidence of Coverage (EOC). 
Without the EOC we are unable to confirm if the requested services are not covered under the dental benefits. 
Therefore, we decided that the Plan has to pre-approve guided tissue regeneration on tooth #4, 5, and 6 
(D4266), endosteal implant on tooth #4 and 6 (D6010), custom fabricated abutment on tooth #4 (D6057), 
implant supported crown on tooth #4 (D6065), and a bone graft on tooth #4 (D6104).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endosteal implant (D6010 x 1), prefabricated 
abutment (D6056 x 1), abutment supported crown (D6058 x1), bone graft (D6104 x 1), and sinus augmentation 
(D7951). 
 
You asked the Plan to pre-approve an implant, abutment, crown, graft, and augmentation. You say that you 
disagree with the denial of dental services. The Plan denied your request. The Plan says your benefits for endosteal implants (D6010), prefabricated abutments (D6056), abutment 
supported crowns (D6058), and bone grafts (D6104) has been exhausted. Sinus augmentation (D7951) is not 
covered by 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, certain limitations apply. The record 
shows your benefits for implants, abutments, crowns, and grafts were exhausted during the processing of this 
request. Sinus augmentation is not covered under this benefit. Therefore, we decided that the Plan does not 
have to pre-approve an endosteal implant (D6010 x 1), prefabricated abutment (D6056 x 1), abutment 
supported crown (D6058 x1), bone graft (D6104 x 1), and sinus augmentation (D7951).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal guard (D9944). 
 
You asked the Plan to pre-approve an occlusal guard (D9944). You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the service requested is not a covered benefit and is 
excluded under the Plan supplemental dental 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 an 
occlusal guard (D9944).
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 you are requesting reconsideration for denial and 
provided medical records. The Plan denied your request. The Plan says based on Medicare guidelines, the 
skilled nursing facility services you are requesting do not meet the requirements for approval. 
 
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 the enrollee has hereditary spastic paraplegia, a urinary tract infection and 
encephalopathy. The enrollee received oral medications, had stable signs and lungs were clear. The enrollee 
was at a moderate to maximal assist with bed mobility and transfers. The enrollee was mobile in the wheelchair 
with stand by assist and required varying assist with activities of daily living. The enrollee does not have daily 
skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional 
nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and 
judgment of a skilled professional therapist. Our reviewer also found the enrollee does not require daily skilled 
nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services (99152) provided on June 30, 
2021. 
 
You asked the Plan to pay for code 99152. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the records do not support the billing of code 99152. 
 
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 99152 is Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, the medical record does not 
contain evidence that moderate sedation was performed with the presence of an independent trained observer. 
Based on this information, we decided that Medicare rules for coverage of code 99152 have not been met. 
Therefore, we decided that the Plan does not have to pay for the moderate sedation services (99152) provided 
on June 30, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Avastin. 
 
You asked the Plan to pre-approve Avastin. The Plan denied your request. The Plan says bevacizumab is not 
recommended for high grade neuroendocrine tumors. 
 
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 Avastin. Our physician reviewer found 
that the enrollee has metastatic poorly differentiated uterine neuroendocrine carcinoma. Avastin is not FDA 
approved for the enrollee's diagnosis. The requested use of the drug is not supported by one of the major drug 
compendia or by clinical research that appears in a CMS-approved medical journal. The documentation does 
not support that the requested drug is safe and effective and otherwise reasonable and necessary for this 
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 Avastin have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Avastin.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing the denial of 
authorization for long term acute care hospital admission. The Plan denied your request. The Plan says based 
on Medicare guidelines and the information we have about the enrollee's condition, they do not 
meet all the requirements. 
 
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 the enrollee was admitted to the acute care hospital with COVID-19 pneumonia 
complicated by altered mental status, respiratory failure requiring intubation and oxygen support. Recent notes 
describe the enrollee as now tolerating low dose oxygen via nasal cannula during the day and BiPAP at night, 
tolerating modified oral diet, but requiring physical, occupational, speech therapy, respiratory toileting, and 
ongoing weaning.  
 The enrollee appears to be more stable and improving and should only require short-term acute care services 
that can safely be administered at the current facility until more appropriate for transfer to a lower level of care.  
The enrollee does not require services at the LTACH that are not available at the current facility. There are no 
services at the LTACH that the enrollee requires that are not already available and covered at the current 
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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the radiologic examinations (X-ray) of the 
shoulder and femur provided on April 29, 2022. 
 
You asked the Plan to waive the copayment for the X-rays. You say that any visit after a surgery is covered for 
three months as per your contract. The Plan denied your request. The Plan says you have been charged the 
correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for diagnostic tests in a specialist office.  
 
You have been asked to pay a $40 copayment for the X-rays. The X-rays fall 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 copayment 
for the radiologic examinations (X-ray) of the shoulder and femur provided on April 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic testing and an urgent care visit 
provided on May 5, 2022. 
 
You asked the Plan to waive the copayment for diagnostic testing and an urgent care visit. You say that these 
charges should be covered. The Plan denied your request. The Plan says the copayments applied are 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 $10 
copayment for diagnostic tests and $50 copayment for urgent care visits.  
 
 You have been asked to pay a total of $60 copayment for diagnostic testing and an urgent care visit. Diagnostic 
testing falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. 
The urgent care visit falls within the Urgently Needed Services benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for diagnostic testing and an urgent care visit provided on May 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on May 12, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
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 office visit provided on May 12, 2022, by an out-
of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve diagnostic facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. You say that you would usually start with a steroid 
facet joint injection. The Plan denied your request. The Plan says that the denial of authorization for this 
service is correct, because the enrollee has not had facet joint injections in the past and there is no 
contraindication to diagnostic medial branch blocks. 
 
The Plan follows Medicare rules. Medicare rules state that diagnostic facet joint interventions are only covered 
under certain circumstances. 
 
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 facet joint injections. Our reviewer says 
that the enrollee meets the Medicare criteria for the requested facet joint injections. Our physician reviewer 
found the enrollee has chronic axial low back pain and the request is for bilateral facet joint injections. A 
physician may provide either intra-articular injections or medial branch blocks for diagnostic and therapeutic 
purposes. This request is medically reasonable and 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 facet joint injections have been met. Therefore, we decided that the Plan has to 
pre-approve diagnostic facet joint injections.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for external prosthetics provided on April 18, 
2022. 
 
You asked the Plan to waive the coinsurance for external prosthetics. You say that the price increased, and you 
cannot afford the increase. The Plan denied your request. The Plan says the coinsurance applied 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 for each Medicare-covered prosthetic device and related supplies. 
 
You have been asked to pay $195.36 which is 20% of the allowed amount for external prosthetics. The allowed 
amount is $976.80(20% x $976.80= $195.36). External prosthetics falls within the Prosthetic Devices 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 coinsurance for external prosthetics 
provided on April 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on March 9, 
2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that you never had to pay this in 
the past and you shouldn't have to now. The Plan denied your request. The Plan says the copayment applied 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 $35 
copayment per visit for a specialist.  
 
You have been asked to pay $35 copayment for specialist office visit. Specialist office visits fall within the 
Physician/Practitioner Services, Including Doctors Office Visits 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 specialist office visit provided on March 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on May 9, 2022. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that this was not the specialist you 
had meant to see, therefore, you feel the copayment should be waived. The Plan denied your request. The Plan 
says the copayment applied was correct. Per your medical records, you were still seen by this provider. 
 
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 $15 
copayment for physician/practitioner services, including doctors office visits.  
 
You have been asked to pay a $15 copayment for a specialist visit. A specialist visit falls within the 
Physician/Practitioner Services, Including Doctors Office Visits 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 a specialist visit provided on May 9, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services provided on December 7, 
2021. 
 
You asked the Plan to pay for the services provided. You say that the code was billed accurately. The Plan 
denied your request. The Plan says the billed service cannot be 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. 
 We find that CPT code 99153 is not supported. This code identifies the technical component of a service. There 
is a more comprehensive code that describes the professional component. Based on this information, we 
decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have 
to pay for the moderate sedation services provided on December 7, 2021.