Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services coded as 99100 and 99140 provided 
on April 30, 2021. 
 
You asked the Plan to pay for the anesthesia services. You say that you would like this claim reprocessed based 
on the medical documentation provided. The Plan denied your request. The Plan says these services are always 
bundled into payment for other services not specified and no separate payment is made per Medicare. 
 
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 99100 is anesthesia for patient of extreme age, younger 
than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure). The CPT Code Manual definition of code 99140 is anesthesia complicated by emergency conditions (specify) (List 
separately in addition to code for primary anesthesia procedure). 
 
We find that CPT code 99140 and 99100 is not supported in the medical record. Specifically, CPT codes 99100 
and 99140 has a status indicator of B meaning that payment for this service is always bundled into another 
procedure. Separate payment is not made for CPT codes 99100 and 99140. Based on this information, we 
decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided 
that the Plan does not have to pay for the anesthesia services coded as 99100 and 99140 provided on April 30, 
2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia 60 mg/ml syringe. 
 
You asked the Plan to pre-approve Prolia. You say that this should be covered. The Plan denied your request. 
The Plan says the enrollee has not tried and failed the required drugs, alendronate, risedronate and zoledronic 
acid. 
 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 Prolia. Our reviewer says that Prolia is 
not medically necessary. Our physician reviewer found the provided documentation does not indicate that the 
enrollee has tried and failed the Plan's required drugs, alendronate, risedronate and zoledronic acid. The 
reviewer also found that there is no indication that the plan's required drugs would likely be less effective 
and/or likely have adverse effects for the enrollee. Therefore, the reviewer found that the step therapy criteria 
has 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 Prolia have not been met. Specifically, the file shows that the enrollee has not 
tried and failed the required drugs. Therefore, we decided that the Plan does not have to pre-approve Prolia 60 
mg/ml syringe.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99213, 11721) provided January 6, 2021. 
 
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the claim must be billed to the enrollee's primary insurer. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has requested an 
explanation of benefits from the enrollee's primary insurer. As the secondary insurer, the Plan cannot be held 
responsible for the office visit until the primary insurer has denied the claim for these services. Therefore, we 
decided that the Plan does not have to pay for an office visit (99213, 11721) provided January 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency abation (RFA). 
 
You asked the Plan to pre-approve radiofrequency abation (RFA). You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that RFA is only covered for certain indications. 
 
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 radiofrequency abation (RFA).  Our reviewer says that the documentation does not support that the requested services are medically reasonable 
or necessary. Our physician reviewer found the enrollee has neck pain which was formerly treated with cervical 
radiofrequency ablation in February 2019 with excellent results. However, the pain has returned after two and a 
half years. The LCD require that diagnostic medical branch blocks be repeated if the RFA was performed more 
than two years ago. Therefore, the requested repeat RFA is not a covered benefit. The enrollee does not meet 
criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency abation (RFA) have not been met. Therefore, we decided that 
the Plan does not have to pre-approve radiofrequency abation (RFA).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab tests (82306, 83735) provided June 2, 2021. 
 You asked the Plan to pay for the lab tests. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the services were performed for screening purposes and are non-covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The lab services in this case were requested solely for screening purposes. The claim was billed with diagnosis 
code Z0000. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the 
Plan does not have to pay for lab tests (82306, 83735) provided June 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the hip orthosis and related supplies provided on September 
9, 2019. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the 
reasonableness of the equipment has not been established. 
 
The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone 
regarding the furnishing of a covered item except under specific circumstances. 
 
 We looked at the file and Medicare rules. The Plan states that the orthoses at issue appear to have been ordered 
by an unsolicited outreach telephone call to the enrollee. This request was not initiated by the enrollee or the 
enrollee's treating physician. The record does not show that written permission was obtained to make contact 
by telephone regarding the furnishing of the items. The record does not show that contact was initiated 
regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the 
past 15 months. Based on this information, we decided that Medicare rules for coverage of the services 
provided have not been met. Therefore, we decided that the Plan does not have to pay for the hip orthosis and 
related supplies provided on September 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services (D0150, D2332, D4341, D2393) provided 
June 9, 2021. 
 
You asked the Plan to pay for the dental services. You say that the dentist was abusive, and the plan should not 
make further payment to the provider. The Plan denied your request. The Plan says the services were paid 
according to the members 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.  
 
 The Plan covers intraoral x-rays and comprehensive oral evaluations covered at 100% when services are 
rendered by a network provider, resin-based composite is covered at 50%, and periodontal scaling and root 
planning is covered at 30% when services are rendered by a network provider. 
 
We looked at the plan contract, the file, and Medicare rules. The record shows the plan paid the appropriate 
amount of $433.30 for the dental services at issue based on the Evidence of Coverage. Please note that 
complaints regarding quality of service must be addressed by the Health Plan or provider directly. Therefore, 
we decided that the Plan does not have to pay any additional amount for the dental services provided June 9, 
2021.
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 the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 continues to receive acute care services and these have not been denied. 
The medical record does not indicate that the enrollee requires services that she is not currently receiving but 
that would be available at the LTACH 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiac device evaluation services provided on April 13, 
2021. 
 
You asked the Plan to pay for the services provided. You say that the documentation supports the billed 
charges. The Plan denied your request. The Plan says the code should be reported in a hospital setting. 
 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 G2066 is Interrogation device evaluation(s), (remote) up 
to 30 days; implantable cardiovascular physiologic monitor system, implantable loop recorder system, or 
subcutaneous cardiac rhythm monitor system, remote data acquisition(s), receipt of transmissions and 
technician review, technical support and distribution of results.  
 
We find that CPT code G2066 is a technical component only code. This code is covered only as diagnostic and 
therefore does not have a related professional code. Based on this information, we decided that Medicare rules 
for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to 
pay for the cardiac device evaluation services provided on April 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), complete upper denture 
(D5110), and complete lower denture (D5120) provided on May 3, 2021. 
 
You asked the Plan to pay for the dental services. You say that your dentures are broken, there is a partial tooth 
missing, and 2 teeth that are glued on. You say that you cannot chew or bite your food. You say that your 
current dentures are 6 years old. You also say that you already paid your 70% share. The Plan denied your 
request. The Plan says you pay a 70% coinsurance for complete dentures when provided in network. The Plan 
also says limited oral evaluation is not listed as a covered 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 and dentures are listed is covered, there 
is a 30% coinsurance that applies. The record shows that the contracted rate for a complete upper denture is 
$1,074. $1,704 x 70% coinsurance = $751.80. The record shows that the contract rate for a complete lower 
denture is $1,044. $1,044 x 70% = $730.80. This is a contractual obligation you agreed to when you enrolled in 
the Plan?s dental coverage. Additionally, the limited oral evaluation is not among those covered under this 
benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), 
complete upper denture (D5110), and complete lower denture (D5120) provided on May 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 31, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent 
nor urgent and prior authorization was not obtained to provide out-of-network care. 
 
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 the laboratory services provided on March 31, 
2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on June 25, 
2021. 
 
You asked the Plan to pay for the CT scan. The Plan denied your request. The Plan says an appropriate 
modifier was not billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
The file shows that CPT code 70450 was billed with code 70496. We find that code 70450 may be eligible for 
separate payment when billed with this code pair. The claim provided does not show that the code at issue was 
billed with an appropriate modifier. Based on this information, we decided that Medicare rules for coverage of 
the CT scan have not been met. Therefore, we decided that the Plan does not have to pay for the computed 
tomography (CT) scan provided on June 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the preventive medicine counseling (99401) provided on 
June 13, 2021. 
 
You asked the Plan to pay for the preventive medicine counseling. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says this service is not covered 
by Medicare. 
 
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 99401 is preventive medicine counseling and/or risk 
factor reduction intervention(s) provided to an individual (separate procedure); approximately 15 minutes. 
 
 
 
 
  
We find that CPT code 99401 is not supported in the medical record. Specifically, code 99401 is assigned a 
status indicator of ?N? under the Physician Fee Schedule, which means that this code is not covered by 
Medicare. Based on this information, we decided that Medicare rules for coverage of the preventive medicine 
counseling have not been met. Therefore, we decided that the Plan does not have to pay for the preventive 
medicine counseling (99401) provided on June 13, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. 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 required drug, zoledronic acid. 
 
 
  
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 Prolia. Our reviewer says that Prolia is 
not medically necessary. Our physician reviewer found the provided documentation does not show that the 
enrollee has tried and failed the required drug, zoledronic acid. The reviewer found that there is no indication 
that the plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. 
Therefore, the reviewer found that the step therapy criteria has 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 Prolia have not been met. Specifically, the enrollee has not tried and failed the 
required drug. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 7, 2021. 
 
You asked the Plan to pay for the testing services. You say that the tests results were needed to help determine 
the course of treatment. The Plan denied your request. The Plan says the claim denied correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
The file shows that FoundationOne Liquid CDx testing was provided. 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 testing services. Our physician reviewer found that the documentation 
enrollee has squamous cell carcinoma of the skin, scalp, and neck. The records do not show that the results of 
the testing would be used for management of the enrollee for a specific treatment strategy. The review has 
determined that the records do not show the testing at issue was medically reasonable and necessary to treat the 
enrollee's condition. 
 
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 testing services have not been met. Therefore, we decided that the Plan does 
not have to pay for the genetic testing provided on May 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) rendered by the out-of-network 
(OON) provider on June 2, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the office visit (99213) rendered by the out-of-network (OON) provider on June 2, 
2021.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay more for the frames and lenses. We decided that the Plan does not have to 
fully pay for the frames and lenses.  
 
You asked the Plan to pay more for the frames and lenses. You say that you paid $60 for the eye exam and 
$606.40 for the glasses. You say that you are disappointed with the minimal payment of $140. The Plan says 
that the claim processed correctly. 
 
We decided that the Plan has to pay more for the frames and lenses.  
 
The records show the Plan only paid $140 instead of $200 toward the frames and lenses due to the eye exam 
copayment. The copayment for an eye exam does not lessen the allowance amount the Plan should pay toward 
the eyewear. Therefore, we decided that the Plan has to pay the full $200 allowance for the frames and lenses 
purchased on January 5, 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.