Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for denosumab with administration, an 
electrocardiogram (EKG), strain imaging with transthoracic echocardiography (TTE) testing, laparoscopic 
cholecystectomy surgery, and office visits provided from October 27, 2021, to December 21, 2021. 
 
You asked the Plan to waive the cost-sharing for Part B drugs, diagnostic tests, outpatient surgery, and office 
visits. You say that you are appealing these cost-sharing amounts. The Plan denied your request. The Plan says 
the cost-sharing amounts you are being charged 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 20% 
coinsurance for Part B drugs, $45 copayment for each diagnostic test, $395 copayment for outpatient surgery, 
$15 copayment for each primary care visit, and $45 copayment for each specialist visit when provided in-
network. A summary of your cost-sharing is shown below: 
 
Date of Service Service Provided 
Allowed 
Amount 
Cost-Share Per 
Contract 
Your Cost-Share 
Responsibility 
October 27, 2021 Specialist Visit $206.01 $45 copayment $45 
November 23, 2021 Specialist Visit $203.64 $45 copayment $45 
November 29, 2021 Primary Care Visit $110.75 $15 copayment $15 
November 30, 2021 EKG $67.49 $45 copayment $45 
December 2, 2021 Imaging & TTE $237.76 $45 copayment $45 
December 7, 2021 Specialist Visit $156.59 $45 copayment $45 
December 10, 2021 Outpatient Surgery $6,068.09 $395 copayment $395 
December 17, 2021 Primary Care Visit $110.75 $15 copayment $15 
December 21, 2021 Part B Drugs $1,004.62 20% coinsurance $200.93 
Total    $850.93 
 
Therefore, your total cost-sharing amount is $850.93. 
 
You have been asked to pay 20% coinsurance for Part B drugs, $45 copayment for each diagnostic test, $395 
copayment for outpatient surgery, $15 copayment for each primary care visit, and $45 copayment for each 
specialist visit. Part B drugs, diagnostic tests, outpatient surgery, and office visits fall within the "Medicare Part 
B Prescription Drugs", "Outpatient Diagnostic Tests and Therapeutic Services and Supplies", "Outpatient 
Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers, and 
"Physician/Practitioner Services, Including Doctor's Office Visits" benefit categories. 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 cost-sharing for denosumab with administration, an electrocardiogram (EKG), strain imaging with 
transthoracic echocardiography (TTE) testing, laparoscopic cholecystectomy surgery, and office visits provided 
from October 27, 2021, to December 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FreeStyle Libre 2 sensor (CPT code K0553) provided on 
December 14, 2021. 
 
You asked the Plan to pay for the sensor. You say that you submitted medical documentation for review of 
medical necessity. The Plan denied your request. The Plan says they did not receive information to verify the 
sensor is necessary. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 pay for the sensor. Our physician reviewer found 
there is no clear documentation that the enrollees insulin treatment regimen requires frequent adjustment by 
the enrollee on the basis of blood glucose monitoring (BGM) or CGM testing results. Records report the 
continuous glucose monitor is being requested because the enrollee "does not like to check their glucose 
levels." 
 
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 sensor have not been met. Therefore, we decided that the Plan does not have 
to pay for the FreeStyle Libre 2 sensor (CPT code K0553) provided on December 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the alveoloplasty, removal of residual tooth roots (D7250, 
D7311, D7310, D7210) provided on January 7, 2022. 
 
You asked the Plan to pay for the alveoloplasty, removal of residual tooth roots. You say that the services 
should be covered as you disagree with the charges. The Plan denied your request. The Plan says the services 
denied correctly as they do not fall within 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 Plan's 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. The Plan contract also says they will pay a maximum of $2,000 of 
your dental services, you are responsible for 100% of the charges after that maximum is met. Therefore, 
we decided that the Plan does not have to pay for the alveoloplasty, removal of residual tooth roots 
(D7250, D7311, D7310, D7210) provided on January 7, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the epidurography services (72275-59) provided on July 23, 2021. 
 
You asked the Plan to pay for the epidurography services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says the use of the 59 modifier to bypass 
the NCCI edit is 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. 
 
In this case, we have confirmed that code 72275 is a column II code to column I code 62321; however, 72275 
was billed with a modifier.  
 
We asked our coder 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 epidurography services. Our reviewer says that the 
documentation does not support payment for this service as billed. Our reviewer found the documentation does 
not support CPT 72275 as a distinct separate service as indicated by the use of the 59 modifier. Epidurography 
should not be billed for the usual work of fluoroscopy and dye injection that is integral to the injection. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the epidurography services have not been met. Therefore, we decided that the 
Plan does not have to pay for the epidurography services (72275-59) provided on July 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the resin-based composites-one surface, 
posterior (D2391 x 2) provided on March 7, 2022 that were paid by the Plan. Additionally, the Plan does not 
have to pay for the third resin-based composite (D2391) provided on March 7, 2022.  
 
You asked the Plan to waive the cost share. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayments has been applied correctly to 
the services paid in this case. Additionally, the third filling provided in this case has been denied correctly as 
you had exceeded the frequency for this benefit.   
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 $25 
copayment for restorations (fillings) rendered by an in-network/out-of-network provider. Additionally, two 
procedure codes per calendar year are covered for this service.  
 
You have been asked to pay $279. This amount includes a $25 copayment x 2= $50 for the fillings provided in 
this case. Additionally, this amount includes $229 for the third filling provided that was denied by the Plan. 
Your contract with the Plan states that two restorations (fillings) are covered per calendar year. On this day, 
three fillings were provided. The Plan had issued payment for two of these fillings. Therefore, the benefit had 
been exhausted and you exceeded the allowable frequency for this service. 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 copayments for the resin-based composites-one surface, posterior (D2391 x 2) provided on  
March 7, 2022 that were paid by the Plan. Additionally, the Plan does not have to pay for the third resin-based 
composite-one surface, posterior (D2391) provided on March 7, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a crown on tooth #2 (D2740). 
 
You asked the Plan to pre-approve a crown. You say that the crown is needed to prevent further fracturing to 
the point where the tooth is not restorable. The Plan denied your request. The Plan says that the documentation 
does not show a need for replacing the existing crown. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a crown when 
the services are medically necessary and reasonable. 
 
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 a crown. Our reviewer says that the 
criteria for coverage has been met. Our physician reviewer found that the documentation indicates that 
recurrent caries is present on the mesial margin which is not accessible unless the current crown is removed. 
Therefore, the placement of a new crown is medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a crown have been met. Therefore, we decided that the Plan has to pre-approve 
a crown on tooth #2 (D2740).  
 
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 pay for crowns (D2750/D2950) and x-ray (D0220) provided on 
February 17, 2022. 
 
You asked the Plan to pay for crowns (D2750/D2950) and x-ray (D0220). You say that the services are covered 
under your plan. The Plan denied your request. The Plan says the yearly benefit allowance for the x-ray 
coverage has been exceeded and the enrollee did not opt into the comprehensive dental services to cover the 
crowns. 
 
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, the requested crowns are not among 
those covered under this benefit. The x-ray was previously covered on January 24, 2022, so the claim was 
denied for exceeding the benefit allowance for the calendar year. Therefore, we decided that the Plan does not 
have to pay for crowns (D2750/D2950) and x-ray (D0220) provided on February 17, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trivisc (previously GenVisc 850). 
 
 
You asked the Plan to pre-approve Trivisc. You say that the preferred medications are not offered as treatment 
in the provider's office. The Plan denied your request. The Plan says the enrollee has not tried and failed at least 
2 of Euflexxa, Synvisc, and Synvisc One. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Trivisc. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided records do not indicate that the 
enrollee has tried and failed the plan's preferred step one alternative. The record does not indicate that the 
enrollee has a contraindication to, or would have an adverse effect from the plan's preferred step one 
alternative.  The elements of the coverage criteria are not satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Trivisc have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Trivisc (previously GenVisc 850).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Keytruda. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found Pembrolizumab is not FDA approved for 
the treatment of papillary (differentiated) or anaplastic thyroid cancer. Use is not supported by major drug 
compendia or the medical literature for either of these types of thyroid cancer. There is no documentation that 
there is testing for Tumor mutational burden (TMB) or microsatellite instability (MSI). No molecular testing 
has been provided on the tumor. The service is not reasonable or medically 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 Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have surgical cutting of nerves surgical cutting of nerves. 
 
You asked the Plan surgical cutting of nerves surgical cutting of nerves. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that an initial thermal RFA of cervical, thoracic, or 
lumbar paravertebral facet joint (medial branch) nerves is considered medically reasonable and necessary for 
patients who meet specific 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 surgical cutting of nerves surgical cutting of nerves. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found enrollees must 
achieve 80% sustained relief of primary (index) pain with at least 2 MBBs. This was not achieved and 
therefore, the request is considered 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 surgical cutting of nerves have not been met. Therefore, we decided that the 
Plan does not have surgical cutting of nerves surgical cutting of nerves.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel provided on June 7, 2021. 
 
You asked the Plan to pay for the testing services. You say that the panel will guide appropriate medical 
management. The Plan denied your request. The Plan says one code must be submitted for the panel. 
 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 the gene panel was billed with multiple codes. If a single procedure is performed, only one code 
with one unit of service may be reported for the procedure. Based on this information, we decided that 
Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does 
not have to pay for the gene panel provided on June 7, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a pontic on tooth #29 and 30 (D6245) and retainer crowns 
(D6740) on tooth # 28 and 31. 
 
You asked the Plan to pre-approve a pontic and crowns. You say that there was a one-space fixed bridge in 
place for many years, but the front anchor tooth became infected and required extraction. You say that now this 
procedure is needed for a two-space fixed bridge. The Plan denied your request. The Plan says the 
documentation provided does not demonstrate any specific need or condition that precludes the use of a 
removable prosthesis. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a pontic and 
crowns when the services are medically necessary and reasonable. 
 
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 a pontic and crowns. Our reviewer says 
that the criteria for coverage has been met. Our physician reviewer found the current bridge is defective and 
must be removed to treat the caries, and a replacement would be needed to restore the quadrant to adequate 
masticatory function. Therefore, a replacement fixed bridge replacing tooth # 29 and 30 with pontics (D6245) 
using tooth # 28 and 31 as abutment retainers is medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a pontic and crowns have been met. Therefore, we decided that the Plan has to 
pre-approve a pontic on tooth #29 and 30 (D6245) and retainer crowns (D6740) on tooth # 28 and 31.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (CPT code 81513) provided on 
January 10, 2022. 
 
You asked the Plan to pay for the lab services. You say that your previous insurance always used to pay for 
your laboratory services. The Plan denied your request. The Plan says the claim in question is being billed with 
an invalid place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the laboratory service (CPT code 81513) provided on January 10, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc (J7325). 
 
You asked the Plan to pre-approve Synvisc. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, Orthovisc, Supartz 
FX, Durolane, Monovisc, or Synvisc-One. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Synvisc. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided documentation does not indicate 
that the enrollee has tried and failed the preferred drugs. The reviewer found that there is no indication that the 
plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. 
Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Synvisc (J7325).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99153) provided October 14, 2021. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim was not billed with a valid place of service. 
 
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 in the medical record. Specifically, the code has a professional 
component / technical component indicator of 3. This code is not eligible for payment in the inpatient setting. 
Based on this information, we decided that Medicare rules for coverage of the physician services have not been 
met. Therefore, we decided that the Plan does not have to pay for physician services (99153) provided October 
14, 2021.