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

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the arm joint 
(73221). 
 
You asked the Plan to pre-approve an MRI of the arm joint. The Plan denied your request. The Plan says the 
enrollee has not completed six weeks of provider directed treatment. The Plan also says there was no contact 
with the enrollee's provider after completing treatment. 
 
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 arm joint. Our reviewer 
says that an MRI of the arm joint is not reasonable and necessary for the enrollee. Our physician reviewer 
found the enrollee has chronic atraumatic right shoulder pain. Recent encounter showed no red flag to mandate 
immediate MRI. The enrollee was offered but declined subacromial steroid injection. Our reviewer found that 
the enrollee was given instructions and exercise bands at his orthopedic encounter of October 25, 2022. There 
have been supervised visits with physical therapy, and no documentation concerning their compliance with the 
home exercise program or success/failure if they have, in fact, complied with the encounter given program. Our 
physician reviewer also found that medical necessity of the requested MRI of the right shoulder has not been 
established in the records provided. 
 
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 arm joint have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a magnetic resonance imaging (MRI) of the arm joint (73221).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99204) provided on June 15, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient service. You say that the service was medically necessary. The 
Plan denied your request. The Plan says prior 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 the office visit (99204) provided on June 15, 2022, 
by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that you disagree with the Plan's 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 Euflexxa is covered when there is documentation in 
the enrollee's medical record must support the patient failed to respond adequately over a three-month period to 
a past history of treatment with analgesics and conservative nonpharmacological therapy (exercise or physical 
therapy, weight loss if appropriate, use of assistive devices). 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 Euflexxa. 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 a diagnosis of osteoarthritis of the knee. The Food and Drug 
Administration has stated that the requested drug is indicated for the enrollee's condition. However, the record 
indicates that the enrollee has not attempted physical therapy. The documentation does not document that the 
enrollee failed to respond adequately over a three-month period to a past history of treatment with analgesics 
and conservative nonpharmacological therapy. Therefore, 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft  retained natural tooth  first 
site in quadrant tooth #30 (D4263), and surgical placement of implant body: endosteal implant tooth #'s 2, 12, 
14 and 30 (D6010). 
 
You asked the Plan to pre-approve the bone replacement graft  retained natural tooth  first site in quadrant 
tooth #30 (D4263), and surgical placement of implant body: endosteal implant tooth #'s 2, 12, 14 and 30 
(D6010). You say that you need at least 1 implant because there is a big hole in your mouth and you are 
worried it might get an infection. You also say that you would agree with 1 implant only, and not 4 that is 
indicated by the dentist. The Plan denied your request. The Plan says these services are not covered under the 
benefit package. 
 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  retained natural tooth  first site in quadrant tooth #30 (D4263), and surgical 
placement of implant body: endosteal implant tooth #'s 2, 12, 14 and 30 (D6010).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on February 8, 2022, to 
February 10, 2022, at the DRG originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
diagnosis of lactic acidosis is supported by the documentation and medical literature. You say that you disagree 
with the decision to delete the secondary diagnosis code and the denial should be overturned. The Plan denied 
your request. The Plan says the records do not support diagnosis code E87.2. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services with secondary diagnosis code E87.2, defined as acidosis. 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 inpatient hospital services at the DRG 
originally billed. Our reviewer says that the decision to remove the secondary diagnosis code and adjust the 
DRG is upheld. Our physician reviewer found the documentation does not consistently and completely support 
the assigned secondary diagnosis code.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on February 8, 2022, to February 10, 2022, at the DRG originally 
billed.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve Accu-Chek SmartView diabetic testing supplies. 
 
You asked the Plan to pre-approve Accu-Chek SmartView supplies. You say that the enrollee has been using 
these test strips for 6 years and changing to a different strip could confuse the enrollee therefore jeopardizing 
health. The Plan denied your request. The Plan says that the enrollee has not tried and failed the Plan's 
preferred brands of Ascensia/Bayer or OneTouch products. 
 
The Plan follows Medicare rules. Medicare rules state that plans may limit coverage to certain DMEPOS 
brands; however, enrollees must have access to all medically-necessary items and supplies of non-preferred 
manufacturers. 
 
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 Accu-Chek SmartView supplies. Our 
reviewer says that the enrollee meets criteria for the requested non-preferred brand supplies. Our physician 
reviewer found it is reasonable to provide the strips the enrollee is currently using. According to the treating 
provider's assessment, the enrollee is using these correctly and would be at risk for using a different brand 
incorrectly due to dementia. The enrollee does take medications that can cause low blood sugar so checking 
blood sugar is important for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Our physician found that the non-preferred 
rand Accu-Chek SmartView is medically necessary for the enrollee. Based on this information, we decided that 
Medicare rules for coverage of Accu-Chek SmartView supplies have been met. Therefore, we decided that the 
Plan has to pre-approve Accu-Chek SmartView diabetic testing supplies.  
 
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 copayment for office visits provided on October 12, 2022, 
to November 13, 2022. 
 
You asked the Plan to waive the copayment for office visits. You say that you are disputing the share cost. The 
Plan denied your request. The Plan says this cost sharing was charged 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 $40 
copayment for Physician/Practitioner services, including doctors office visits.  
 
You have been asked to pay $40 copayment for each office visit. This item/service falls within the 
Physician/Practitioner services, including doctors 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 office visits provided on October 12, 2022, to November 13, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for discharge day management services provide on July 11, 
2022. 
 
You asked the Plan to pay for inpatient discharge. You say that you would like the decision to be reversed and 
your claim be re-adjudicated for payment at the maximum amount allowed. The Plan denied your request. The 
Plan says Original Medicare is responsible for payment. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for discharge day management services provide on July 11, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a single photon emission computed tomography 
(SPECT). 
 
You asked the Plan to pre-approve the SPECT. You say that the enrollee needs to be evaluated for Parkinson's 
disease. The Plan denied your request. The Plan says the requested scan is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 the SPECT. Our reviewer says that the 
SPECT is not medically necessary. Our physician reviewer found that the record indicates that the enrollee has 
right sided rest tremor of their hand and bradykinesia. The national coverage criteria do not list this condition 
as a covered indication for the requested service. Up to date states that the available evidence suggests that the 
overall accuracy of DaTscan for parkinsonian syndromes is equal to but not better than the accuracy of a 
carefully obtained clinical diagnosis. The record provided does not establish the medical necessity and 
reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria 
are not satisfied. 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the SPECT have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a single photon emission computed tomography (SPECT).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the extraspinal chiropractic manipulative 
treatments (98943) provided on July 19, 2022 and August 2, 2022. 
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these services are 
not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to issue reimbursement for the extraspinal chiropractic manipulative treatments 
(98943) provided on July 19, 2022 and August 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on July 20, 
2022. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged 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 $30 
copayment for physician/practitioner services/specialist.  
 
You have been asked to pay a $30 copayment for a specialist office visit. This item/service falls within the 
physician/practitioner services/specialist 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 a specialist office visit provided on July 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is very motivated to return home, and an 
IRF admission will optimize the enrollee's level of function prior to returning home. The Plan denied your 
request. The Plan says the IRF admission is not considered reasonable and medically necessary. 
 
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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 85060 billed for date of service August 29, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the medical records document the billed units. 
The Plan denied your request. The Plan says an inappropriate place of service was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 We find that CPT code 85060 was billed with 22, an outpatient hospital place of service code. No payment is 
recognized for code 85060 furnished to hospital outpatients. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code 85060 billed for date of service August 29, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 7, 2022, to 
February 28, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that an NOA is not required for each 
date of service. The Plan denied your request. The Plan says the claim has not been billed with the correct 
admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 We looked at the file and the Medicare rules. We find that the claim at issue was not billed with an admission 
date for the first period of care in 2022 as required. Based on this information, we find that the Medicare rules 
for payment of the claim at issue have not been met. Therefore, we decided that the Plan does not have to pay 
for the home health services provided from February 7, 2022, to February 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99214 billed for date of service July 7, 2022. 
 
You asked the Plan to pay for the billed services. You say that you have not received payment. The Plan denied 
your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file shows that the services at issue were reimbursed by the Plan 
on August 4, 2022. A comparison of the two claims shows these are exact duplicates. There is no evidence to 
support that the billed services were provided twice on the same date. Based on this information, we decided 
that the Medicare rules for the billed services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99214 billed for date of service July 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite - one surface, anterior (D2330 x2) 
provided on October 24, 2022. 
 
You asked the Plan to pay for the dental services. You say that the 2-year requirement, which you or the dentist 
were not aware of was within 5 weeks of the visit. You also say that although these fillings are preventative in 
nature, keeping your teeth healthy is extremely important. The Plan denied your request. The Plan says your 
benefit for the requested item or 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 Plans 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 item or service was exhausted on date of service December 16, 2020. 
Therefore, we decided that the Plan does not have to pay for a resin-based composite - one surface, anterior 
(D2330 x2) provided on October 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on April 28, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the lab services. You say that the documents support the need for services. The 
Plan denied your request. The Plan says prior 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 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 lab services provided on April 28, 2022, by an out-of-network (OON) 
provider.