Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a complete series of radiographic images (D0210) provided 
on May 18, 2021. 
 
You asked the Plan to pay for a complete series of radiographic images. You say that you were informed by 
your dentist that bitewing x-rays are included so you feel that you should be reimbursed for at least the regular 
cost of bitewing x-rays. The Plan denied your request. The Plan says this service is not a covered benefit. 
 
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 for a 
complete series of radiographic images (D0210) provided on May 18, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF 
admission. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve admission to a SNF. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found based on the medical records 
provided there is no documentation that the enrollee requires skilled nursing services on a daily basis. The 
enrollee does require skilled therapy services; however, not on a daily basis. This enrollee does not require the 
services on an inpatient basis, only in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of admission to a SNF have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for targeted genomic sequence analysis panel testing (81455) 
provided on April 20, 2021. 
 
You asked the Plan to pay for targeted genomic sequence testing. You say that this test was ordered by the 
treating physician to help determine the course of treatment. The Plan denied your request. The Plan says the 
denial of payment for this test is correct, because this test is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that code 81455 is not covered.  
 
We looked at the file and Medicare rules. This test is not covered by Medicare. Based on this information, we 
decided that Medicare rules for coverage of targeted genomic sequence testing have not been met. Therefore, 
we decided that the Plan does not have to pay for targeted genomic sequence analysis panel testing (81455) 
provided on April 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a Computed Tomography (CT) scan of 
blood vessels in the abdomen and pelvis (74174) and a CT scan of blood vessels in the chest (71275) provided 
on September 14, 2020. 
 
You asked the Plan to waive the copayment for CT scans of blood vessels. You say that you would like the 
Plan to pay the $100 balance due to the provider, as listed on the bill you received from the provider. The Plan 
denied your request. The Plan says the cost-share was applied correctly. The service at issue is a Medicare-
covered benefit, but the copayment is a contractual agreement that cannot be waived. 
 
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 $100 
copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  You have been asked to pay a $200 copayment for two CT scans of blood vessels. CT scans of blood vessels 
fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. The EOC 
states the copayment is for each Medicare-covered radiological diagnostic service ($100 ? 2 CT scans = $200). 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for a Computed Tomography (CT) scan of blood vessels in the 
abdomen and pelvis (74174) and a CT scan of blood vessels in the chest (71275) provided on September 14, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee scooter and a walking boot provided on October 28 
and November 6, 2020, by a supplier not enrolled in the Medicare program. 
 
You asked the Plan to pay for a knee scooter and a walking boot. You say that the items at issue were an urgent 
medical necessity for you. The Plan denied your request. The Plan says rules for payment have not been met 
because the supplier of the items at issue is not enrolled in the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for a knee scooter and a walking boot 
provided on October 28 and November 6, 2020, by a supplier not enrolled in the Medicare program.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for psychotherapy visits provided on May 24, 2021 to June 18, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for psychotherapy visits. You say that you rendered treatment to the enrollee in good 
faith. The Plan denied your request. The Plan says the denial of payment for these services is correct, because 
this provider is out-of-network with the Plan and authorization was not obtained.  
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 psychotherapy visits provided on May 24, 2021 to 
June 18, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services (97813, 97814) and infrared therapy 
services (97026) provided January 1, 2020 to August 27, 2020. 
 
You asked the Plan to pay for the acupuncture and infrared therapy services. You say that please reconsider 
your acupuncture denial claims for payment. The Plan denied your request. The Plan says infrared therapy is 
not a covered benefit. The claims were submitted past the timely filing limitation. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service.  
The record shows that a claim for the acupuncture and infrared therapy services was not filed until July 02, 
2021. This means that more than one calendar year from the date of service had passed before a claim was 
filed. Therefore, we decided that the Plan does not have to pay for the acupuncture services (97813, 97814) and 
infrared therapy services (97026) provided January 1, 2020 to August 27, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration for spinal surgery for the 
enrollee. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says medical studies haven't proven that this procedure is helpful for treatment of the 
health problem. 
 
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 the procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found bone marrow aspirate remains experimental for use in spinal surgery as bone graft material. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bone marrow aspiration for spinal surgery for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cold pad with pump purchased on June 25, 2021. 
 
You asked the Plan to pay for this item. You say that this equipment should be covered by the Plan. The Plan 
denied your request. The Plan says a cold pad with pump is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The rules specifically state a circulating cold pad with pump is not covered. The item at issue 
in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general 
public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does 
not have to pay for a cold pad with pump purchased on June 25, 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 for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires a long term acute 
level of care with highly specialized care team. The Plan denied your request. The Plan says that the enrollee's 
records show his wound is not complex and does not require complex wound care only available in an LTACH 
setting. 
 
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. The enrollee 
does not require services at the LTACH that are not available at the acute care hospital where he is currently 
receiving care. All medically necessary care is being provided in the current acute care facility. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete upper denture (D5110) provided on March 6, 
2021. 
 
You asked the Plan to pay for the dental service. You say that you were told that the dentures were medically 
necessary. The Plan denied your request. The Plan says the complete upper denture is not listed as a covered 
service. The Plan also says that you signed a financial agreement acknowledging that this service is not 
covered. 
 
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 denture is not among those covered 
under this benefit. Additionally, the record shows that you were aware that this service would not be covered 
by your plan. Therefore, we decided that the Plan does not have to pay for the complete upper denture (D5110) 
provided on March 6, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2 additional Euflexxa injections for the left knee and 5 
Euflexxa injections for the right knee. 
 
You asked the Plan to pre-approve 2 additional Euflexxa injections for the left knee and 5 Euflexxa injections 
for the right knee. You say that the additional 2 Euflexxa injections for the left knee and 5 Euflexxa injections for the right knee are medically necessary. The Plan denied your request. The Plan says the additional 2 
Euflexxa injections for the left knee are not medically necessary and the requested 5 Euflexxa injections for the 
right knee do not meet criteria. 
 
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 2 additional Euflexxa injections for the 
left knee and 5 Euflexxa injections for the right knee. Our reviewer says that the additional 2 Euflexxa 
injections for the left knee are not medically necessary and the requested 5 Euflexxa injections for the right 
knee do not meet criteria. Our physician reviewer found the record indicates that the enrollee has osteoarthritis 
of the knees.  The record indicates that the enrollee had a Synvisc one injection less than six months ago on 
October 22, 2021.  The record indicates that five injections are requested for the left knee. This exceeds the 
FDA approved labeling instructions. The elements of the coverage rules are not satisfied.  The requested 
service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 2 additional Euflexxa injections for the left knee and 5 Euflexxa injections for 
the right knee have not been met. Therefore, we decided that the Plan does not have to pre-approve 2 additional 
Euflexxa injections for the left knee and 5 Euflexxa injections for the right knee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for remote monitoring services provided from 
February 4, 2021, to March 17, 2021. 
 
You asked the Plan to waive the copayment for remote monitoring services. You say that the services should be 
covered as you had them done before and had no copay. The Plan denied your request. The Plan says the 
copayment applied correctly based on the services rendered. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for Physician/Practitioner services, including doctor's office visits.  
 
 
 You have been asked to pay a $40 copayment for three remote monitoring visits ($40 x 3 = $120).  
The record shows that the provider is a cardiology specialist. Remote monitoring services fall within the 
Physician/Practitioner services, including doctor's office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for remote monitoring services provided from February 4, 2021, to March 17, 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 is not 
medically necessary. 
 
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 admission to a LTACH is not medically necessary. Our physician reviewer found there is no 
documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving 
appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are 
not available at the acute care hospital where she is currently receiving care. There are no services available at 
the LTACH that the enrollee requires that are not available at the health care setting being offered by the health 
plan. The requested LTACH service are not medically necessary, reasonable, and appropriate for the diagnosis 
and condition of the enrollee. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the electrocardiogram (EKG) you had on 
July 14, 2021. 
 
You asked the Plan to waive the copayment for the EKG. You did not provide an explanation in your appeal 
request. The Plan denied your request. The Plan says you were charged this copayment correctly.  The Plan 
says that because the allowed amount for this service ($16.14) is less than your copayment obligation, you are 
responsible for the full allowed amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for non-radiological diagnostic services.  
 
You have been asked to pay a $20 copayment for the EKG. The EKG falls within the non-radiological 
diagnostic 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 the 
electrocardiogram (EKG) you had on July 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the exploration of a spinal fusion (22830), the reinsertion of 
a spinal fixation device (22849), and the removal of posterior segmental instrumentation (22852) provided on 
January 7, 2020. 
 
You asked the Plan to pay for the exploration of a spinal fusion, the reinsertion of a spinal fixation device, and 
the removal of posterior segmental instrumentation. You say that these codes are supported in the records. The 
Plan denied your request. The Plan says these codes are not documented. 
 
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 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 exploration of a spinal fusion, the reinsertion of a spinal 
fixation device, and the removal of posterior segmental instrumentation. Our reviewer says that these codes are not supported. Our reviewer found the operative report does not support 22830 as a separate procedure. 
Modifier 59 should be used to distinguish a different session, patient encounter, or different procedure or 
surgery, different anatomical site or injury. This code with modifier 59 cannot be verified by the operative 
report. The operative report does not document reinsertion of spinal fixation device. The documentation 
describes release of paraspinal, erector spinae, creating a flap. 22849 is the incorrect code to report for this 
service. The operative report also does not document removal posterior segmental instrumentation. The 
documentation describes release of paraspinal, erector spinae, creating a flap. 22852 is the incorrect code to 
report for this service. 
 
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 exploration of a spinal fusion, the reinsertion of a spinal fixation device, and 
the removal of posterior segmental instrumentation have not been met. Therefore, we decided that the Plan 
does not have to pay for the exploration of a spinal fusion (22830), the reinsertion of a spinal fixation device 
(22849), and the removal of posterior segmental instrumentation (22852) provided on January 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids provided on February 12, 2021. 
 
You asked the Plan to pay for the hearing aids. You say that you were told you would be reimbursed a 
minimum of $375 per ear and a maximum of $2,075 per device. You say that you didn't want to go to anyone 
new and full reimbursement should be approved. The Plan denied your request. The Plan says the hearing aids 
were not purchased through the Plan's hearing aid vendor. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when they are received from a network provider.  
 
We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Specifically, the hearing aids were not purchased from the 
Plans hearing aid vendor. Therefore, we decided that the Plan does not have to pay for the hearing aids 
provided on February 12, 2021.