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

 
We decided that the Plan does not have to pay for procedure code 64447 billed for date of service April 4, 
2022. 
 
You asked the Plan to pay for procedure code 64447. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3.  
 
In this case, the MUE for CPT code 64447 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 64447 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 64447 billed for date of service April 4, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on July 1, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for chiropractic services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says prior authorization was not obtained for these services. 
 
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 chiropractic services provided on July 1, 2022, by 
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 3, 2022, by an 
OON provider. 
 
You asked the Plan to pay for laboratory services. The Plan denied your request. The Plan says the out-of-
network 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 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 August 3, 
2022, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit for observation (D9430) provided by an out-
of-network provider on June 15, 2022. 
 
You asked the Plan to pay for an office visit for observation. You say that you believe the Plan should pay for 
this. The Plan denied your request. The Plan says the rendered dental work 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an office 
visit for observation (D9430) provided by an out-of-network provider on June 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the maxillary immediate denture (D5130) provided on May 
3, 2022. 
 
You asked the Plan to pay for the maxillary immediate denture. You say that you had impressions taken and 
were told you had to go back in a few weeks. You also say that in the meantime, you were advised this 
provider no longer accepted your insurance, and you will not be going back to them. The Plan denied your 
request. The Plan says you have a liability of $615.00 for this immediate denture. 
 
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, you are responsible for $615.00 for the 
maxillary immediate denture according to the patient charge schedule. Therefore, we decided that the Plan does 
not have to pay for the maxillary immediate denture (D5130) provided on May 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the Part B drugs, the Myocardial perfusion 
imaging, and the catheter placement provided on February 22, 2022, and July 7, 2022. 
 
You asked the Plan to waive the cost share for the Part B drugs, the Myocardial perfusion imaging, and the 
catheter placement. You say that you feel you should not be responsible for this cost share amount, and you would like the Plan to reconsider your request. 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 20% 
coinsurance for Medicare Part B prescription drugs, a $275 copayment for diagnostic radiology services, and a 
$325 copayment for outpatient surgery.  
 
You have been asked to pay a 20% coinsurance for the Part B drugs, totaling $49.03. This item/service falls 
within the Medicare Part B prescription drugs benefit category. You have also been asked to pay a $275 
copayment for the Myocardial perfusion imaging. This item/service falls within the Outpatient diagnostic tests 
benefit category. Finally, you have also been asked to pay a $325 copayment for the catheter placement in an 
outpatient hospital setting. This item/service falls within the Outpatient surgery benefit category. This means 
that you have been asked to pay the correct amounts based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the cost share for the Part B drugs, the Myocardial perfusion imaging, and the catheter 
placement provided on February 22, 2022, and July 7, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on June 9, 2022. 
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says services from non-
participating providers are not covered unless they are authorized by the Plan before the services are provided. 
 
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 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 psychotherapy provided on June 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve abdomen infraumbilical panniculectomy. 
 
You asked the Plan to pre-approve abdomen infraumbilical panniculectomy. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that abdominal lipectomy/panniculectomy is covered 
when specific criteria are met. 
 
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 abdomen infraumbilical 
panniculectomy. Our reviewer says that the services are not medically necessary. Our physician reviewer found 
in this case; the record indicates that you have had weight loss after bariatric surgery. The record indicates your 
pannus does not extend beneath your pubis. The documentation does not indicate that you have intertrigo 
refractory to three months of conservative treatment. The elements of the coverage criteria are not satisfied. 
The requested service is not 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 abdomen infraumbilical panniculectomy have not been met. Therefore, we 
decided that the Plan does not have to pre-approve abdomen infraumbilical panniculectomy.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-rays provided on March 23, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for x-rays. You say that you are requesting reconsideration. The Plan denied your 
request. The Plan says the enrollee's network primary care provider (PCP) or plan must give the enrollee 
approval in advance before the enrollee can use providers not in the plan's network. This is called giving you a 
"referral." 
 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 x-rays provided on March 23, 2022, 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 office visits provided on April 5, 2022 to May 4, 2022, 
by an OON provider. 
 
You asked the Plan to pay for the office visits. You say that the provider's office told you that they were in-
network with your Plan.  The Plan denied your request. The Plan says the out-of-network 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 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 visits provided on April 5, 2022 to May 
4, 2022, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found as a qualifying diagnosis is not 
clearly supported in the records, then the ventilator at issue does not meet Medicare criteria for medically 
necessary and reasonable for this enrollee. In addition, provided records document that the home ventilator is 
being requested for use in a pressure support mode which could be provided by a bilevel positive airway 
pressure (BiPAP) device with average volume assured pressure support and a back-up rate. As stated in the Local Coverage Determination (L33800): "Claims for ventilators used to provide continuous positive airway 
pressure (CPAP) or bi-level CPAP therapy for conditions described in this RAD policy will be denied as not 
reasonable and necessary." 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the crown (D2740) provided on June 20, 2022. 
 
You asked the Plan to pay more for the crown. You say that prior to receiving this service, you were advised 
that the treating provider was in-network, and that your share of the cost would be $315.00. The Plan denied 
your request. The Plan says your annual dental benefit maximum 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 annual dental benefit was exhausted when this claim was reprocessed for payment for date of 
service June 20, 2022. Therefore, we decided that the Plan does not have to pay more for the crown (D2740) 
provided on June 20, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has iron deficiency anemia 
despite oral iron replacement. She has not tried and failed the Plan's required drugs, Infed and Venofer. The 
records do not show that the required drugs would be contraindicated or less effective; therefore, Injectafer is 
not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Injectafer.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pre-transplant testing provided to the enrollee on June 30, 
2022. 
 
You asked the Plan to pay for the testing. You say that the service should be covered due to medical necessity. 
The Plan denied your request. The Plan says the services from an out-of-network provider were not authorized 
by the plan. 
 
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 pre-transplant testing provided to the enrollee on 
June 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and a complete 
intraoral x-ray series (D0210) provided on June 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says your benefit for the requested items or services 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 items or services was exhausted on date of service February 11, 2021. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and a 
complete intraoral x-ray series (D0210) provided on June 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on January 06, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says enrollees generally must receive care from a network provider. In most cases, care 
the enrollee receives from an out-of-network provider (a provider who is not part of our plans network) will 
not be covered. 
 
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 lab testing provided on January 06, 2022, by an 
out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray of the left foot (73630) provided 
on April 5, 2022. 
 
You asked the Plan to waive the copayment for an x-ray. You say that you should not have a copayment for 
services provided in-network. You say you should not have been billed. 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 $15 
copayment for x-ray services.  
 
You have been asked to pay a $15 copayment for an x-ray. This service falls within the outpatient diagnostic 
tests and therapeutic services and supplies 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 an x-ray of the left foot (73630) provided on April 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on June 
8, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that you feel the Plan should pay for 
this in-network exam as if it is a first-time claim. 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 March 22, 2021. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) 
provided on June 8, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc injections. 
 
You asked the Plan to pre-approve the requested services. You say that it is painful to walk. The Plan denied 
your request. The Plan says you have not tried and failed steroid injections for 3 months. 
 
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 the requested services. Our physician 
reviewer found that you have osteoarthritis of the knee. The record does not indicate that you have tried and 
failed conservative nonpharmacologic therapy and simple analgesics. The provided radiograph report does not 
demonstrate the presence of osteoarthritis. The FDA has not stated that the requested drug is indicated for your 
condition. The Medicare approved drug compendia do not contain a supportive citation for the use of the 
requested drug in your clinical situation. The elements of the coverage criteria 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Synvisc injections.