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

 
We decided that the Plan does not have to waive the copayment for services you received at an oncologist's 
office on January 14, 2021, and January 19, 2021. 
 
You asked the Plan to waive the copayment for the specialist services. You say that you were not charged these 
copayments for services in 2020. The Plan denied your request. The Plan says you were charged these 
copayments correctly.  The Plan says that the reason you were not charged a copayment for similar services 
you received in December of 2020 is because you had met your 2020 annual out-of-pocket maximum. You had 
not met your annual out-of-pocket maximum for 2021 services. 
 
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 $45 
copayment per visit for specialist services.  
 You have been asked to pay a $45 copayment per visit for the specialist services. 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 services you received at an oncologist's office on January 14, 2021, and January 19, 
2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ultrasound (76705) provided June 21, 2021. 
 
You asked the Plan to pay for the ultrasound. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the procedure code billed shares a bundled relationship with another code 
billed. 
 
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 shares a bundled relationship with 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 an ultrasound (76705) 
provided June 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for scaling in presence of generalized moderate or severe 
gingival inflammation - full mouth (D4346) provided by a participating provider on March 29, 2021. 
 
You asked the Plan to pay for scaling in presence of generalized moderate or severe gingival inflammation. 
You say that you were told that everything would be covered. The Plan denied your request. The Plan says the 
services that were provided are 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 scaling in 
presence of generalized moderate or severe gingival inflammation - full mouth (D4346) provided by a 
participating provider on March 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (70450) provided June 26, 2021. 
 
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the billed code shares a bundled relationship with another code billed. 
 
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 
shares a bundled relationship with 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 
radiology services (70450) provided June 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional supplies related to a public health emergency 
(99072) provided March 18, 2021. 
 
You asked the Plan to pay for the additional supplies. You say that the service was medically necessary. The 
Plan denied your request. The Plan says this procedure code is not eligible for separate payment. 
 
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 99072 is not supported in the medical record. Specifically, per the National Physician 
Fee Schedule, this code has a status of "B" and payment is always bundled with payment for another service. 
Based on this information, we decided that Medicare rules for coverage of the additional supplies have not 
been met. Therefore, we decided that the Plan does not have to pay for additional supplies related to a public 
health emergency (99072) provided March 18, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for rivaroxaban, 10 mg tablet (A9270) provided in an outpatient 
setting on June 24, 2021. 
 
You asked the Plan to pay for the self-administered drug. You say that you are not aware of any self-
administered drugs being provided on the date of service in this case. The Plan denied your request. The Plan says the drug you received is considered self-administered. The Plan says self-administered drugs are covered 
under a Medicare Part D prescription drug plan. The Plan also says the drug you received is not covered under 
Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for rivaroxaban, 10 mg tablet 
(A9270) provided in an outpatient setting on June 24, 2021.  
 
Benefits for the self-administered drug 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a retained crown - porcelain (D6750), and pontic-porcelain 
(D6240) provided by an out-of-network provider on May 20, 2021. 
 
You asked the Plan to pay for a retained crown-porcelain, and pontic-porcelain. You say that you would like 
the Plan to pay for these charges. The Plan denied your request. The Plan says D6750 and D6240 are not 
covered dental services. 
 
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 retained crown - porcelain (D6750), and pontic-
porcelain (D6240) provided by an out-of-network provider on May 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 1, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says this is included the 
clinical trial costs. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pay for the lab services as part of a clinical trial. The Plan does not cover 
routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pay 
for the lab services provided on February 1, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency ambulance transportation 
(A0427, A0425) rendered on May 22, 2021. 
 
You asked the Plan to waive the copayment for emergency ambulance transportation. You say that you did not 
want to go by ambulance. You also say that your husband could have driven you by car, but the doctor would 
not discharge you unless you went by ambulance. The Plan denied your request. The Plan says you were 
charged the correct cost sharing 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 $250 
copayment for each one-way Medicare-covered ground ambulance trip.  
 
You have been asked to pay a $250 copayment for emergency ambulance transportation. Emergency 
ambulance transportation falls within the Ambulance 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 emergency ambulance transportation (A0427, A0425) rendered on May 22, 2021.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve boost complete nutritional supplement. 
 
You asked the Plan to pre-approve the supplement. You say that this is medically necessary. The Plan denied 
your request. The Plan says the records do not show a requirement to eat through a tube. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to pre-approve boost complete nutritional supplement.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services can be safely received in other settings, for example, a skilled nursing 
facility. 
 
 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for pneumonia, sepsis, and congestive heart failure. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the medical record supports a need for physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation for the enrollee. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested service has not been shown by research to be helpful. 
 
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 injection. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this is considered an experimental/ investigational procedure because of the wide variation in efficacy 
reported in the literature. Therefore, the request is deemed 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 the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sacroiliac joint radiofrequency ablation for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the 
abdomen and pelvis you had on June 1, 2021. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you had to have two CT scans and 
you stated that the second one came back negative.  You do not think you should have to pay two separate 
copayments. The Plan denied your request. The Plan says you were charged this copayment correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 
copayment for radiological diagnostic services.  
 
You have been asked to pay a $100 copayment for the CT scan. This copayment applies regardless of the 
reason for the service. The CT scan falls within the 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 computed tomography (CT) scan of the abdomen and 
pelvis you had on June 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (81185, 81404, 81407, 81408, 81479, 
81401, 81403, 81405, 81406) provided on February 18, 2021. 
 You asked the Plan to pay for laboratory services. You say that this was medically necessary. The Plan denied 
your request. The Plan says this was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place 
where the sample was taken is reported as the Place of Service (POS).  
 
We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent 
laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we 
decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that 
the Plan does not have to pay for laboratory services (81185, 81404, 81407, 81408, 81479, 81401, 81403, 
81405, 81406) provided on February 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (99100) provided on July 22, 2021. 
 
You asked the Plan to pay for the anesthesia services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the services were not emergent. There were network providers 
available. 
 
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 services 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 these services. Therefore, we decided 
that the Plan does not have to pay for anesthesia services (99100) provided on July 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided by an out-of-network provider on 
September 4, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
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 services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the services provided by an out-of-network provider on 
September 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve infuse BMP allograft. 
 
You asked the Plan to pre-approve infuse BMP allograft. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve infuse BMP allograft. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found criteria is not met for lumbar fusion surgery. There is no documented adequate 
physical therapy for back pain. Also, BMP allograft is not FDA approved for use in the lumbar spine. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of infuse BMP allograft have not been met. Therefore, we decided that the Plan 
does not have to pre-approve infuse BMP allograft.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda, Fosaprepitant, Alimta, and Carboplatin. 
 
You asked the Plan to pre-approve Keytruda, Fosaprepitant, Alimta, and Carboplatin. You say that the 
medications 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, Fosaprepitant, Alimta, and 
Carboplatin. Our reviewer says that the medication is not medically necessary. Our physician reviewer found 
this is not first line treatment for this enrollee. They have already received prior carboplatin and pemetrexed 
and progressed on recent programmed death-ligand 1 (PD-L1) inhibitor. The service is not reasonable or 
medically necessary or safe and effective or this 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 Keytruda, Fosaprepitant, Alimta, and Carboplatin have not been met. Therefore, 
we decided that the Plan does not have to pre-approve Keytruda, Fosaprepitant, Alimta, and Carboplatin.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided from July 
10, 2020, to August 7, 2020, billed with code OFGA1. 
 
You asked the Plan to pay for SNF services. You say that this was billed correctly. The Plan denied your 
request. The Plan says this was not billed with the correct code. 
 
The Plan must follow Medicare rules. Medicare rules say that SNF services are paid under the SNF PDPM 
PPS. Under this system, each digit of the HIPPS code corresponds to a different case-mix group aspect of the 
SNF care provided. 
 
We looked at the file and Medicare rules. Based on the PDPM calculations worksheet and the conditions 
reported by the SNF, the billed HIPPS code is not correct. The records do not support that the enrollee had both 
a mechanically altered diet and a swallowing disorder. Based on this information, we decided that Medicare 
rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pay 
for skilled nursing facility (SNF) services provided from July 10, 2020, to August 7, 2020, billed with code 
OFGA1.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation - per site 
(D7953) and placement of intra-socket biological dressing to aid in hemostasis or clot stabilization, per site 
(D7922) provided May 8, 2021. 
 
You asked the Plan to pay for the bone replacement grafts and intrasocket biological dressings. You say that 
you were unaware when the services were performed that they were not covered. The Plan denied your request. 
The Plan says these services are not covered under your 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.  Therefore, we decided that the Plan does not have to pay for the bone replacement graft for ridge preservation - 
per site (D7953) and placement of intra-socket biological dressing to aid in hemostasis or clot stabilization, per 
site (D7922) provided May 8, 2021.