Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lightweight wheelchair (CPT code K0003), for the 
enrollee. 
 
You asked the Plan to pre-approve the DME. You say that the DME is medically necessary. The Plan denied 
your request. The Plan says the DME is not 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 DME. Our physician reviewer 
found a lightweight wheelchair (K0003) is not medically necessary per LCD L33788. The documentation does 
not reveal objective treating medical provider progress notes with a physical examination and detailed gait and 
neuromuscular examination of this enrollee supporting that the enrollee has a mobility limitation that 
significantly impairs mobility related activity of daily living (MRADLs) in the home and supporting that this 
deficit cannot be overcome by a standard wheelchair. The documentation does not reveal that the enrollee can 
and does self-propel in a lightweight wheelchair and that this will significantly improve MRADL participation 
in the home. 
 
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a lightweight wheelchair (CPT code K0003), for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural injection. 
 
You asked the Plan to pre-approve an epidural injection. 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 an epidural injection is considered medically 
reasonable and necessary 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 an epidural injection. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the symptoms are consistent with 
T1 radiculopathy, but the CPT code is incorrect. Therefore, the request is deemed not medically necessary or 
reasonable. 
 
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 epidural injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an epidural injection.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Skilled Nursing Facility (SNF) admission. 
 
You asked the Plan to pre-approve the SNF admission. You say that you would like reconsideration because 
you require wound care and physical therapy. The Plan denied your request. The Plan says you do not have any 
daily skilled needs. 
 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 the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found you do not have any parental 
medication; daily complex wound care or nutrition given via a feeding tube.  You are stable without any acute 
exacerbations of chronic medical problems.  Yout physical function is at or near your baseline and you can 
receive services at a lower level of care.  Admission to a SNF for inpatient skilled rehab services is not 
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 the SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Skilled Nursing Facility (SNF) admission.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services to be provided by the 
requested out-of-network provider. 
 
You asked the Plan to pre-approve physical therapy services. The Plan denied your request. The Plan says the 
provider is not part of your insurance. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physical 
therapy services to be provided by the requested out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient diabetes training (G0108) provided on April 1, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient services. You say that the care was rendered in good faith and 
pursuant to the medical needs of the enrollee. The Plan denied your request. The Plan says enrollee?s must 
receive their medical services from an in-network provider with the exception being urgent or emergent 
services. Non-emergent services with non-contracted providers require prior authorization before services 
being rendered. 
 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 outpatient diabetes training (G0108) provided on 
April 1, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the detailed and extensive oral evaluation (D0160), the 
panoramic radiographic image (D0330), diagnostic casts (D0470) and intraoral radiographic image (D0220) 
provided on July 5, 2021. 
 
You asked the Plan to pay for the dental services. You say that you would like additional reimbursement for the 
paid services and payment for the denied services. The Plan denied your request. The Plan says the 
radiographic images were paid at the allowed rate and the diagnostic casts and extensive oral evaluation are not 
covered 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. Specifically, the record indicates that the Plan paid the allowed amount 
for the radiographic images. Additionally, the diagnostic casts are not a covered benefit and per your contract 
with the Plan, the comprehensive detailed oral evaluation is only covered when rendered by a maxillofacial 
surgeon. The record indicates that this provider is a general dentist. Therefore, we decided that the Plan does 
not have to pay for the detailed and extensive oral evaluation (D0160), the panoramic radiographic image 
(D0330), diagnostic casts (D0470) and intraoral radiographic image (D0220) provided on July 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for podiatry services you received with an out-
of-network provider from July 12, 2021, to July 26, 2021. 
 
You asked the Plan to waive the deductible for the out-of-network podiatry services. You say that you were not 
aware that this doctor is no longer in-network. The Plan denied your request. The Plan says you were assessed 
this deductible correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $1500 deductible which applies to out-of-network services.  
 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1500 deductible 
which applies to out-of-network services. This cost sharing is a contractual obligation that had not been met at 
the time the out-of-network podiatry services was received on July 12, 2021, to July 26, 2021. Therefore, we 
decided that the Plan does not have to waive the deductible for podiatry services you received with an out-of-
network provider from July 12, 2021, to July 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the localized delivery of anti-microbial agents (D4381) 
provided on April 14, 2021, and April 23, 2021. 
 
You asked the Plan to pay for the localized delivery of anti-microbial agents. You say that these services were 
necessary. The Plan denied your request. The Plan says these services are not covered by your dental 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 the 
localized delivery of anti-microbial agents (D4381) provided on April 14, 2021, and April 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the arthrocentesis procedure you had at an 
outpatient hospital facility on May 25, 2021. 
 
You asked the Plan to waive the copayment for the arthrocentesis procedure. You say that this procedure was 
unnecessary so you don't think you should have to pay for it. The Plan denied your request. The Plan says you 
were charged this amount correctly. The Plan says that because the allowed amount for this service ($236.35) 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 $295 
copayment for outpatient surgery and other services at an outpatient hospital facility.  
 You have been asked to pay a $295 copayment for the arthrocentesis procedure. The arthrocentesis procedure 
falls within the outpatient surgery and other services at an outpatient hospital facility benefit category. This 
copayment applies regardless of the reason for the procedure. 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 arthrocentesis procedure you had at an outpatient hospital facility on May 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the copayments for the chiropractic services received from 
June 28, 2021, to July 19, 2021. 
 
You asked the Plan to adjust the copayments for the services. You say that the claim was processed 
appropriately. The Plan denied your request. The Plan says all of the in-network providers are further away 
from you. 
 
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 out-of-network chiropractic services.  
 
You have been asked to pay a $20 copayment for the covered manipulative treatment. The services fall within 
the out-of-network chiropractic services benefit category, as the rendering provider is out-of-network. Additionally, there are extra charges for both dates of service for non-covered extraspinal manipulative 
treatment and therapeutic treatment. These services are not covered chiropractic services. Manual manipulation 
of the spine is the only type of chiropractic service that is covered. 
 
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 adjust the copayments for the chiropractic services received from June 28, 2021, to 
July 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown - porcelain fused to noble metal (D2752) and core 
buildup, including any pins when required (D2950) provided July 15, 2021. 
 
You asked the Plan to pay for the crown and core buildup. You say that you thought these services would be 
covered and cannot afford the cost. 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 crown 
- porcelain fused to noble metal (D2752) and core buildup, including any pins when required (D2950) provided 
July 15, 2021.
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 the IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee's needs can be met at a different level of care. 
 
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 based on the medical records provided 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. It is not clear the enrollee would be able to fully benefit and/or participate in an 
IRF 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered by the out-of-network 
(OON) provider on April 7, 2021. 
 
You asked the Plan to pay 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 the services were rendered by an out of 
network provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the 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 laboratory services rendered by the out-of-network (OON) provider on  
April 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography (CT) head or brain (70450) provided 
April 20, 2021. 
 
You asked the Plan to pay for the CT scan. You say that attached you will find both radiology reports which 
supports separate and distinct procedures for CPT 70450 (CT) and CPT 70496 (CTA). The Plan denied your 
request. The Plan says the clinical documentation submitted indicates a CT and CTA were both performed 
during the same encounter and on the same structure. Per NCCI guidelines for reporting a single study, this 
service cannot be separately payable. 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 the CT 
scan is a column II code to column I 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 computed tomography (CT) head or brain (70450) provided 
April 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional units of codes 74177, 76830, and 76856, billed 
for April 18, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services have 
already been paid. 
 
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 additional units of CPT codes 74177, 76830, and 76856, are not supported in the medical record. 
Specifically, the records provided only show that one unit of codes 74177, 76830, and 76856, was provided on 
the date of service in question. These services have been processed and paid by the Plan. The additional billed 
units are not payable. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the additional units of codes 
74177, 76830, and 76856, billed for April 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown - porcelain fused to noble metal (D2752), core 
buildup, including any pins when required (D2950), and endodontic therapy, anterior tooth (excluding final 
restoration) (D3310) provided April 26, 2021, and May 10, 2021. 
 
You asked the Plan to pay for the crown, core buildup and endodontic therapy. You say that a Plan 
representative provided misinformation about your coverage. 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 crown 
- porcelain fused to noble metal (D2752), core buildup, including any pins when required (D2950), and 
endodontic therapy, anterior tooth (excluding final restoration) (D3310) provided April 26, 2021, and May 10, 
2021.  
 
Your complaint about potentially being provided misinformation by a Plan representative is not a valid appeal 
for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare 
does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for facet joint injections (64494) provided on January 8, 2021. 
 You asked the Plan to pay for facet joint injections. You say that this is supported in the records. The Plan 
denied your request. The Plan says the billed units exceed MUE. 
 
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 2.  
 
In this case, the MUE for CPT code 64494 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of facet 
joint injections have not been met. Therefore, we decided that the Plan does not have to pay for facet joint 
injections (64494) provided on January 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve expandable controller (E2377) expandable controller 
harness (E2313) and electronic connection between 2 systems (E2311). 
 
You asked the Plan to pre-approve upgraded electronics. You say that please review the attached medical 
documentation to support the need of the custom medical equipment being requested. The Plan denied your 
request. The Plan says the requested upgraded electronics are not medically necessary as the approved power 
options come with their own switches. 
 
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 upgraded electronics. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation that meets Medicare criteria for medically necessary for 
this enrollee for the upgraded electronics. Provided records indicate the enrollee has 4/5 grip strength in her 
upper extremities and is independent with upper body dressing and feeding thus indicating that she has 
adequate upper extremity strength and function to operate the wheelchair's power options with their own 
switches. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve expandable controller (E2377) expandable controller harness (E2313) and 
electronic connection between 2 systems (E2311).