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

 
We decided that the Plan does not have to pre-approve Epifix. 
 
You asked the Plan to pre-approve Epifix. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria 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.  
 
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 Epifix. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the review indicates that the incisions from the removal of the ankle hardware are improving 
with the current wound care regimen. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Epifix have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Epifix.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the vedolizumab injection provided on 
October 28, 2022. 
 
You asked the Plan to waive the coinsurance for the injection. You say that this payment should be waived or 
lowered as you cannot afford it and plan to continue receiving this drug injection. The Plan denied your 
request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B drugs.  
 
You have been asked to pay up to 20% coinsurance for the injection. This item/service falls within the 
Medicare Part B drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the 
vedolizumab injection provided on October 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on December 8, 
2022. 
 
You asked the Plan to pay for the dental service. You say that you are appealing the denied services because 
they were medically necessary for the enrollee to receive. The Plan denied your request. The Plan says your 
benefit for the requested item or service has already been exhausted. Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the enrollees benefit for the requested item or service was exhausted on the date of service of 
November 14, 2022. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation 
(D0140) provided on December 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic imaging services and a medical belt provided in 
the Republic of Lebanon from June 14, 2022, to September 23, 2022. 
 
You asked the Plan to pay for diagnostic imaging and medical belt. You say that you hurt your back from 
falling while out of the country and needed these services. The Plan denied your request. The Plan says these 
services were not urgent or emergent in nature so are not covered by the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services furnished outside of the 
United States and its territories are excluded from Medicare coverage except in limited, specified 
circumstances. The Plan has a worldwide coverage benefit that goes beyond Medicare's coverage. For that 
reason, the Plans rules apply. The Plan covers worldwide emergency and urgent care services. 
 
We looked at the file and Medicare rules. These services do not fall within any of the circumstances for which 
Medicare covers out-of-country services. Additionally, these services do not meet the Plans rules for coverage 
because they were not urgent or emergent in nature. Based on this information, we decided that Medicare rules 
for coverage of diagnostic imaging and medical belt have not been met. Therefore, we decided that the Plan 
does not have to pay for diagnostic imaging services and a medical belt provided in the Republic of Lebanon 
from June 14, 2022, to September 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 80053, 83036, 80061, and 84443 provide don October 
28, 2022. 
 
You asked the Plan to pay for codes 80053, 83036, 80061, and 84443. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the services billed are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 80053, 83036, 80061, and 84443 are not supported in the medical record. Specifically, 
the documentation submitted did not include documentation of lab results of comprehensive metabolic panel 
was performed; therefore, code 80053 cannot be verified. 
 
The documentation submitted did not include documentation of lab results of hemoglobin; glycosylated (A1C) 
was performed; therefore, code 83036 cannot be verified. 
 
The documentation submitted did not include documentation of lab results of lipid panel was performed; 
therefore, code 80061 cannot be verified. 
 
The documentation submitted did not include documentation of lab results of thyroid simulating hormone was 
performed; therefore, code 84443 cannot be verified. 
 
Based on this information, we decided that Medicare rules for coverage of codes 80053, 83036, 80061, and 
84443 have not been met. Therefore, we decided that the Plan does not have to pay for codes 80053, 83036, 
80061, and 84443 provide don October 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for the specialist office visit provided on 
December 19, 2022. 
 
You asked the Plan to reduce the cost share for the specialist office visit. You say that you were told that your 
doctor was considered in-network. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $1,000 deductible which applies to an OON specialist office visit.  
 
The item or service you asked the Plan to waive the copayment for falls within the physician/practitioner 
services, including doctor's office benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 deductible which applies to OON physician/practitioner services, including 
doctor's office. This cost sharing is a contractual obligation that had not been met at the time the specialist 
office visit was received on December 19, 2022. Therefore, we decided that the Plan does not have to reduce 
the cost share for the specialist office visit provided on December 19, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9338 billed for date of service April 7, 
2022. 
 
You asked the Plan to pay for procedure code S9338. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
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 S9338 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9338 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9338 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9338 billed for date of service April 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 35371-AS-59-LT, 37221-AS-59-LT, 37223-
AS-59-LT, and 34812-50-AS-59 billed for date of service August 30, 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 codes are 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 CPT code. In this case, we have confirmed that codes 
35371 and 34812 are column II codes to column I code 35302. Codes 37221 and 37223 are column II codes to 
column I code 34705. This claim has not been billed with an appropriate modifier to bypass the edit. The -59 
modifier is not supported as a separate and distinct procedural service. 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 codes 35371-AS-59-LT, 37221-AS-59-
LT, 37223-AS-59-LT, and 34812-50-AS-59 billed for date of service August 30, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve an MRI of the cervical spine. 
 
You asked the Plan to pre-approve MRI of the cervical spine. You say that you would like reconsideration 
because the services are medically necessary. The Plan denied your request. The Plan says that an MRI of the 
cervical spine is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve MRI of the cervical spine. Our reviewer 
says that the requested MRI is medically necessary Our physician reviewer found that due to your severe 
degenerative x-ray findings, ataxia, imbalance and positive spurling's test you meet the criteria for an MRI of 
the cervical spine. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MRI of the cervical spine have been met. Therefore, we decided that the Plan 
has to pre-approve a MRI of the cervical spine.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kerecis Omega3. 
 
You asked the Plan to pre-approve Kerecis Omega3. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 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.  
 
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 Kerecis Omega3. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee's wound is improving with treatment. The requested Kerecis Omega3 is 
not medically necessary because the records show the wound is improving with 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 Kerecis Omega3 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Kerecis Omega3.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computer-assisted surgery services (0055T). 
 
You asked the Plan to pre-approve computer-assisted surgery. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
experimental/investigational. 
 
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 computer-assisted surgery. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that there are no large-volume, long-term/high-quality clinical studies that confirm the clinical benefits (ultimate outcomes of functional improvement and pain reduction) of computer-
assisted surgery over standard surgical approaches in total knee arthroplasty. No compelling rationale is 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of computer-assisted surgery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve computer-assisted surgery services (0055T).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of the lumbar spine. 
 
You asked the Plan to pre-approve MRI of the lumbar spine. You say that the enrollee has lower back pains. 
The Plan denied your request. The Plan says an MRI of the lumbar spine is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve MRI of the lumbar spine. Our reviewer 
says that the requested MRI of the lumbar spine is not medically necessary. Our physician reviewer found that 
there is no documentation showing evidence of severe and progressive neurological abnormalities. The 
examination that was provided did not corroborate any significant lumbar abnormalities to coincide with the 
pain. Additionally, a lumbar x-ray has not been performed to show medical necessity of the requested MRI. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MRI of the lumbar spine have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an MRI of the lumbar spine.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each specialist visit. 
 
You asked the Plan to waive the copayment for each specialist visit. You say that you should not have to pay 
copayments for the requested services. The Plan denied your request. The Plan says the cost sharing will be 
applied according to the Plan contract. 
 
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 $30 
copayment for each specialist visit.  
 
 
  You have been asked to pay a $40 copayment for each specialist visit. This item/service falls within 
physician/practitioner 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 
OT visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 84436, 84480 and 85048 billed for date of 
service June 14, 2022. 

You asked the Plan to pay for procedure codes 84436, 84480 and 85048. You say that these services were 
necessary and are supported as billed. The Plan denied your request. The Plan says payment for codes 84436, 
84480 and 85048 is bundled into payment for codes 84439, 84481 and 85025. 
 
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 84436 
is a column II code to column I code 84439 with a modifier indicator of 0. In addition, we have confirmed that 
code 84480 is a column II code to column I code 84481 with a modifier indicator of 0. The column II codes are 
therefore not payable. We have also confirmed that code 85048 is a column II code to column I code 85025 
with a modifier indicator of 1. This service 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 codes 84436, 84480 and 85048 billed for date of service June 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214-25) provided on September 7, 2022. 
 
You asked the Plan to pay for the office visit. You say that the claim should be paid. The Plan denied your 
request. The Plan says the service is not supported by the records. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the office visit have not been met. Review of the file shows that 
code 99214-25 remains not supported. This code is included in the global day period of code 20611. This 
means it cannot be separately reimbursed. The submitted documentation does not support a significant, 
separately identifiable evaluation and management service to support the use of the -25 modifier. Therefore, we 
decided that the Plan does not have to pay for the office visit (99214-25) provided on September 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam CT capture and interpretation with field of view 
of both jaws; with or without cranium (D0367) provided on August 19, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are asking the Plan to reverse or dismiss 
this charge. The Plan denied your request. The Plan says your benefit for the requested service dollar limit was 
met. The Plan paid your full annual dental allowance of $1,500 prior to the processing of this claim. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service July 25, 2022. Therefore, 
we decided that the Plan does not have to pay for a cone beam CT capture and interpretation with field of view 
of both jaws; with or without cranium (D0367) provided on August 19, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for influenza virus vaccine, quadrivalent (IIV4), split virus, preservative 
free, 0.5 mL dosage, for intramuscular use identified with code 90686 provided on October 8, 2022. 
 
You asked the Plan to pay for influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.5 
mL dosage, for intramuscular use. You say that you disagree with the Plan's denial. The Plan denied your 
request. The Plan says that payment is not allowed for this service because it is not 
appropriate for the procedure codes billed. 
 
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 has denied this code stating that "payment is not allowed for this 
service because it is not appropriate for the procedure codes billed". No explanation on why this code is not 
appropriate. No other denial rationale was provided. Therefore, we decided that the Plan has to pay for 
influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.5 mL dosage, for intramuscular use 
identified with code 90686 provided on October 8, 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.