Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic testing provided on February 17, 
2022. 
 
You asked the Plan to waive the copayment for diagnostic testing. You say that you dont even know what the 
test is for so you shouldn't be charged. The Plan denied your request. The Plan says the copayment applied is 
correct. 
 
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 $30 
copayment for specialty physician for other Medicare covered outpatient diagnostic tests.  
 
 
 
 
 You have been asked to pay $24.59 which is less than the standard $30 copayment for diagnostic testing. 
Diagnostic testing 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 diagnostic testing provided on February 17, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) scan of the thorax. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says the person in charge of the enrollee's care no longer feels that this scan is indicated 
following significant improvement in bronchitis. 
 
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 scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found that it should be 
considered that there are no chest x-ray reports in the submitted records. The note from 7/8/22 authored by the 
provider clearly states that since you have has improved, and chest x-ray is negative, further work-up is not 
necessary. Absent a demonstration from your physician that a CT of the chest is medically necessary the exam 
should be denied unless the referring clinician clarifies any remaining medical necessity of same. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve computed tomography (CT) scan of the thorax.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vision care (92133, 92012, 92083, 92020, 1126F, 3288F, 
1101F, 1159F) provided on February 15, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for out-of-network vision care. You say that the enrollee has coverage for these 
services with a policy in the same state they were provided, so these services should be covered. The Plan 
denied your request. The Plan says out-of-network care is only covered in certain limited circumstances. The 
requested services were not pre-approved, and there is no evidence to suggest that this care was urgent or 
emergent. 
 
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 vision care (92133, 92012, 92083, 92020, 1126F, 
3288F, 1101F, 1159F) provided on February 15, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the clinical value and effectiveness of bone marrow aspirate in the 
setting of spinal fusion surgery has not been demonstrated in the peer-reviewed literature. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Detailed 
documentation is not evident regarding a specific indication to support the request for bone marrow aspirate for 
the approved surgery. There is a lack of large volume, long-term peer-reviewed outcome studies to support the 
use of bone marrow aspirate for this enrollees medical condition as discussed above. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception to guidelines. Our physician reviewer found that the enrollee's condition does not meet criteria for 
coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bone marrow aspirate for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthofix Trinity Elite Allograft for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied 
your request. The Plan says that the clinical value and effectiveness of OrthoFix Trinity Elite allograft in the 
setting of lumbar spinal fusion surgery have not been demonstrated in the peer-reviewed literature. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. There is limited 
published, large-scale, long-term peer-reviewed literature that shows mesenchymal stem cells to be an effective 
and/or safe treatment for the enrollee's pathology. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception to guidelines. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Orthofix Trinity Elite Allograft for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied 
your request. The Plan says that the clinical value and effectiveness of bone marrow aspirate in the setting of 
spinal fusion surgery has not been demonstrated in the peer-reviewed literature. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Bone marrow 
aspirate remains experimental. More research is needed to show safety and efficacy. Our physician reviewer 
found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bone marrow aspirate for the enrollee.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a porcelain/ceramic substrate crown for tooth # 31. 
 
You asked the Plan to pre-approve a porcelain/ceramic substrate crown for tooth # 31. You say that a 
porcelain/ceramic substrate crown for tooth # 31 is medically necessary. The Plan denied your request. The 
Plan says that a porcelain/ceramic substrate crown for tooth # 31 is not medically necessary. 
 
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. The Plan covers a 
porcelain/ceramic substrate crown for tooth # 31 when the services are medically necessary and reasonable. 
 
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 porcelain/ceramic substrate crown for 
tooth # 31. Our reviewer says that a porcelain/ceramic substrate crown for tooth # 31 is medically necessary. 
Our physician reviewer found that the provider noted pain in the tooth that was localized to the mesio-lingual 
cusp upon pressure application. This diagnostic of pressure applied to each individual cusp is typically used to 
identify a fracture under a cusp which otherwise cannot be detected.  A fractured cusp commonly is restored 
with the use of a crown, which binds the tooth together and helps prevent further propagation. The clinical 
situation where a tooth is painful upon stresses directed in one axis is known as cracked tooth syndrome, or 
CTS.  Li et al have noted "Full crowns can be the first choice of treatment, both with and without the symptoms 
of CTS . Gutherie and DiFiore claimed that full-coverage crowns best meet the target of treating CTS."   Given 
the narrative provided by way of the clinical notes, a crown would be found to be the appropriate treatment 
modality for what is known as cracked tooth syndrome. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a porcelain/ceramic substrate crown for tooth # 31 have been met. Therefore, 
we decided that the Plan has to pre-approve a porcelain/ceramic substrate crown for tooth # 31.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4342) for tooth 
number 19. 
 
You asked the Plan to pre-approve periodontal scaling and root planing for tooth number 19. You say that 
periodontal scaling and root planing for tooth number 19 is medically necessary. The Plan denied your request. 
The Plan says periodontal scaling and root planing for tooth number 19 is not medically necessary. 
 
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. The Plan covers periodontal 
scaling and root planing (D4342) for tooth number 19 when the services are medically necessary and 
reasonable.  
 
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 periodontal scaling and root planing 
(D4342) for tooth number 19. Our reviewer says that periodontal scaling and root planing for tooth number 19 
is not medically necessary. Our physician reviewer found that the provided x-rays show virtually no bone loss 
around tooth #19 despite the noted abnormal pocket depth readings. Given the lack of any observable bone loss 
around tooth #19, there can be no diagnosis of a periodontal disease that would require treatment under code 
D4342. If abnormal pocketing exists it would be caused by a gingival condition that does not involve loss of 
clinical attachment as would observed in a periodontal condition. The procedure requested does not meet the 
criteria for periodontal scaling and root planing.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of periodontal scaling and root planing (D4342) for tooth number 19 have not 
been met. Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root 
planing (D4342) for tooth number 19.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care, first hour (99291) billed for date of service 
January 15, 2022. 
 
You asked the Plan to pay for critical care. You say that this service was reported appropriately. The Plan 
denied your request. The Plan says this service is not supported as 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, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
 
 
 
 
 
 
 
 
 
 We find that CPT code 99291 is not supported in the medical record. Specifically, the medical record does not 
note the time spent providing this service. Without this information, a time-based code like 99291 cannot be 
verified. Based on this information, we decided that Medicare rules for coverage of critical care have not been 
met. Therefore, we decided that the Plan does not have to pay for critical care, first hour (99291) billed for date 
of service January 15, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments and coinsurance for a computed tomography 
(CT) scan of the thorax, a positron emission tomography (PET) scan, a specialist office visit, and octreotide 
injections provided from November 2, 2021, to November 17, 2021. 
 
You asked the Plan to waive the copayments and coinsurance for the CT scan, PET scan, specialist visit, and 
injections. You say that you cannot afford the bill. The Plan denied your request. The Plan says the correct 
copayments and coinsurance were applied.  
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 $225 
copayment for diagnostic radiology services at an outpatient hospital. 
 
Your contract with the Plan also clearly says that you must pay a $40 copayment for specialist services. 
 
Your contract with the Plan also clearly says that you must pay a 20% coinsurance for Part B drugs. 
 
Service/Drug Allowed Amount Copayment 20% Coinsurance 
CT Scan  November 2, 2021 - $225 - 
Specialist Visit  November 15, 2021 - $40 - 
Octreotide Injection  November 15, 2021 $6,161.10 - $1,232.22 
 $3.80 - $0.76 
PET Scan  November 17, 2021 - $225 - 
Total:  $490 $1,232.98 
 
You have been asked to pay a total of $490 for the CT scan, and PET scan, and specialist visit. The CT scan 
and PET scan fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit 
category. The specialist visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits 
benefit category. You have also been asked to pay a total of $1,232.98 for the injections, which is 20% of the 
allowed amount. The injections falls within the Medicare Part B Prescription Drugs 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 copayments and coinsurance for a computed tomography (CT) scan of the 
thorax, a positron emission tomography (PET) scan, a specialist office visit, and octreotide injections provided 
from November 2, 2021, to November 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 83789 billed for date of service December 
13, 2021. 
 
You asked the Plan to pay for procedure code 83789. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 83789 is bundled into payment for code 80307. 
 
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 83789 
is a column II code to column I code 80307. This claim has not been billed with an appropriate modifier to 
bypass the edit. The -59 modifier is not supported as a separate and distinct procedural service. Based on the 
claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure code 83789 billed for date of service December 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on April 18, 2022. 
 
You asked the Plan to pay for the dental service. You say that the dental office advised your insurance 
company was requiring x-rays. You say that you assumed there would be no charge since your insurance 
required them. You say that the dental office later advised that they require x-rays when doing partials. You 
also say that you should not be responsible for this bill. The Plan denied your request. The Plan says the annual 
maximum benefit has 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 maximum benefit was exhausted on date of service March 28, 2022. The record shows that 
the Plan paid $159 for services received on January 10, 2022, $187 for services received on January 18, 2022, 
$1,072 for services received on February 21, 2022, and $582 for services received on March 28, 2022. $159 + 
$187 + $1,072 + $582 = $2,000. Therefore, we decided that the Plan does not have to pay for the panoramic x-
ray (D0330) provided on April 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a periodic oral evaluation (D0120), 
prophylaxis (D1110), and bitewing x-rays provided on January 26, 2022, and a resin-based composite filling on 
tooth #30 (D2392) provided on January 27, 2022. 
 You asked the Plan to waive the cost share for the dental services. You say that you should have been informed 
of the policy changes from last year. The Plan denied your request. The Plan says you have been 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 30% 
coinsurance for out-of-network preventive dental services. The contract also says that the enrollee must pay 
70% coinsurance after a $50 deductible is met for out-of-network basic dental services. 
 
You have been asked to pay 30% coinsurance for preventive dental services on January 26, 2022. Preventive 
and basic dental services fall within the Dental Services benefit category.  
 
Code Allowed Amount 30% Coinsurance 
D1110 $68 $20.40 
D0120 $35 $10.50 
D0274 $43 $12.90 
Total  $43.80 
 
You have also been asked to pay a total of $145.20 for the basic dental services on January 27, 2022. The 
dental deductible was not met at the time of service; therefore, $50 was applied to satisfy the deductible. The 
Plan has followed Medicare rules by clearly disclosing in the contract that there is $50 deductible which applies 
to out-of-network basic dental services. This cost sharing is a contractual obligation that had not been met at 
the time the basic dental services was received on January 27, 2022.  
 
The allowed amount remaining after you paid your deductible is $136 ($186 original allowed amount - $50 
deductible paid = $136 remaining allowed amount). You have been asked to pay $95.20, which is 70% 
coinsurance of the remaining allowed amount for the basic dental services ($136 remaining allowed amount x 
70% coinsurance = $95.20). 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 cost share for a periodic oral evaluation 
(D0120), prophylaxis (D1110), and bitewing x-rays provided on January 26, 2022, and a resin-based composite 
filling on tooth #30 (D2392) provided on January 27, 2022.