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

 
We decided that the Plan does not have to pre-approve treatment with Stelara. 
 
You asked the Plan to pre-approve Stelara. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve treatment with Stelara.  
 
Benefits for Stelara 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 2, 2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. 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 ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found based on the medical records 
provided there is inadequate documentation that the ventilator at issue meets Medicare criteria for medically 
necessary and reasonable for you. Provided records document the requested ventilatory support with the 
requested ventilator with volume assured pressure support settings could be equally provided with bilevel 
positive airway pressure (BiPAP) with backup rate and with average volume assured pressure support.  As stated in the Local Coverage Determination (L33800): Claims for ventilators used to provide continuous 
positive airway pressure (CPAP) or bi-level CPAP therapy for conditions described in this RAD policy will be 
denied as not 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71250 billed for date of service April 21, 
2022. 
 You asked the Plan to pay for procedure code 71250. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 71250 is bundled into payment for 
code 71275. 
 
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 71250 
is a column II code to column I code 71275. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 71250 billed for date of service April 21, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36253 billed for date of service February 23, 
2022. 
 
You asked the Plan to pay for procedure code 36253. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 36253 is bundled into payment for 
code 37243. 
 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 36253 
is a column II code to column I code 37243. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 36253 billed for date of service February 23, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74176 billed for date of service May 6, 2022. 
 
You asked the Plan to pay for procedure code 74176. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 74176 is bundled into payment for 
code 74177. 
 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 74176 
is a column II code to column I code 74177. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 74176 billed for date of service May 6, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76700 billed for date of service April 16, 
2022. 
 You asked the Plan to pay for procedure code 76700. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76700 is bundled into payment for 
code 93976. 
 
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 76700 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76700 billed for date of service April 16, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve continued acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve continued IRF care. You say that you still need help with walking and 
getting to the bathroom. The Plan denied your request. The Plan says that based on Medicare guidelines, the 
requested IRF services do not meet the requirements for approval. 
 
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 continued IRF care. Our reviewer says 
that the requested continued IRF care is found to be medically reasonable and necessary. Our physician 
reviewer found clinical documentation shows that not all therapy goals have been met yet and you are making 
good progress. You require close medical monitoring and intense therapy of 2 disciplines. Thus, the continued 
stay in IRF is 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 continued IRF care have been met. Therefore, we decided that the Plan has to 
pre-approve continued acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for a computed tomography (CT) scan and 
injection provided on April 7, 2022. 
 
You asked the Plan to waive the cost sharing for a CT scan and injection.. You say that you cannot afford to 
pay the cost share amount. The Plan denied your request. The Plan says the cost sharing applied was 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 a $250 
copayment for diagnostic and nuclear medicine radiological services. Your contract with the Plan also clearly 
says that you must pay a 20% coinsurance for Medicare-covered Part B drugs. The allowed amount of the 
claim is $255.86, resulting in a coinsurance amount of $51.17 ($255.86 x 20%). 
 You have been asked to pay a $250 copayment for a computed tomography (CT) scan and $51.17 for an 
injection for a total of $307.51. A CT scan falls within the Outpatient Diagnostic Tests and Therapeutic 
Services and Supplies benefit category. An injection falls within the Medicare Part B Prescription 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 cost sharing for a CT scan and injection 
provided on April 7, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of the lower extremity. 
 
You asked the Plan to pre-approve an MRI of the lower extremity. The Plan denied your request. The Plan says 
an MRI 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 an MRI of the lower extremity. Our 
reviewer says that an MRI of the lower extremity is not medically necessary. Our physician reviewer found that 
no medical records have been submitted to support the medical necessity of MRI of the right foot. Absent of 
the clinical and plain x-ray findings to support the medical necessity of an MRI of the right foot, the requested 
exam is denied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the lower extremity have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an MRI of the lower extremity.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for a nerve conduction study and related services provided to the enrollee 
on September 30, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the diagnosis code is not valid. 
 
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 2022 edition of ICD-10 Clinical Modification (CM) became active on 
October 1, 2021. However, M54.50 existed as a diagnosis code prior to the 2022 ICD-10 being active. 
Therefore, the plan has not forwarded a valid denial in this case. Therefore, we decided that the Plan has to pay 
for a nerve conduction study and related services provided to the enrollee on September 30, 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 waive the copayments for wound care provided from February 3, 
2022, to March 17, 2022. 
 
You asked the Plan to waive the copayments for wound care. You say that you cannot afford these charges. 
You also say that you did not know this was considered a hospital. The Plan denied your request. The Plan says 
the copayment applied was 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 a $390 
copayment for Medicare-covered outpatient surgery at a hospital.  
 
You have been asked to pay a $1,950 for wound care ($390 x 5 visits). Wound care falls within the Outpatient 
Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers, 
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 copayments for wound care provided from 
February 3, 2022, to March 17, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service May 7, 2022. 
 
You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976.  
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 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76705 billed for date of service May 7, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve private duty nursing services. 
 
You asked the Plan to pre-approve the requested services. You say that you cannot be left alone. The Plan 
denied your request. The Plan says the request is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Private duty nurses are not covered by Medicare or your plan. 
Therefore, we decided that the Plan does not have to pre-approve private duty nursing services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mass spectrometry and tandem mass spectrometry (83789) 
provided on March 16, 2022. 
 
You asked the Plan to pay for mass spectrometry services. You say that these services are supported as billed. 
The Plan denied your request. The Plan says they have agreed to pay for the drug testing services; however, 
this service is not eligible for separate payment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of mass spectrometry services have not been met. Specifically, we find that the testing described by 
the billed code is considered specimen validity testing which is not separately payable. Therefore, we decided 
that the Plan does not have to pay for mass spectrometry and tandem mass spectrometry (83789) provided on 
March 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a custom fabricated abutment (D6057), and an abutment 
supported crown (D6058) provided on May 13, 2022. 
 
You asked the Plan to pay for a custom fabricated abutment, and an abutment supported crown. You say that 
you thought dental services were covered up to $1,000. The Plan denied your request. The Plan says the 
services at issue are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a custom 
fabricated abutment (D6057), and an abutment supported crown (D6058) provided on May 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation (D7953) 
for tooth #19, #21, #24, and #25. 
 
You asked the Plan to pre-approve the dental services.. You say that you are requesting this dental procedure to 
be done. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because bone replacement grafts are not covered by the Plan when they are reported for an edentulous space or 
an extraction site. 
 
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 replacement graft for ridge preservation (D7953) for tooth #19, #21, #24, and #25.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the consultation (D9310) and cone 
beam computed tomography (CT) image capture (D0383) provided on April 4, 2022. 
 
You asked the Plan to pay an additional amount for the dental services. You say that you were not aware that 
the provider was out of network. You also say that no one ever told you this was the case. The Plan denied your 
request. The Plan says the consultation was reprocessed with a $25 copayment, instead of $97. The Plan also 
says that cone beam CT is not listed as a covered dental service. 
 
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. Therefore, we decided that the Plan does not have to pay an additional 
amount for the consultation (D9310) and cone beam computed tomography (CT) image capture (D0383) 
provided on April 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for endodontic therapy (D3310) and resin-based 
composite fillings (D2332, D2331) provided on February 16, 2022. 
 
You asked the Plan to waive the cost share for endodontic therapy and fillings. You say that you told the 
provider they could not go over the $3,000 limit. The Plan denied your request. The Plan says that your annual 
dental maximum has been met. 
 
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 this benefit includes coverage up to $3,000 for preventive and comprehensive dental services. The contract says that the enrollee is 
responsible for any amount above the annual maximum amount. 
 
The record shows you have met your annual dental maximum amount during the processing of this claim. You 
have been asked to pay the non-covered amount of $520 for endodontic therapy and two fillings. Endodontic 
therapy and fillings fall within the Dental 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 
cost share for endodontic therapy (D3310) and resin-based composite fillings (D2332, D2331) provided on 
February 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on May 
18, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that you were unaware that you 
could only have one comprehensive oral evaluation every three years. You also say that if you have to pay for 
this service, it will put a financial hardship on you. The Plan denied your request. The Plan says your benefit 
for the requested 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 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 service was exhausted on date of service August 5, 2021. Therefore, we 
decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on May 18, 2022.