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

 
We decided that the Plan does not have to pay for a new patient visit (99203), a diagnostic dental procedure 
(41899), and a biopsy of the tongue (41100) provided by an oral surgeon on December 22, 2021. 
 
You asked the Plan to pay for the oral procedures performed by an oral surgeon. You say that you want the 
services covered. The Plan denied your request. The Plan says the provider you selected for the services you 
received has opted out of Medicare. This means the provider chose not to receive Medicare funds and 
therefore, the Plan cannot pay the charges. 
 
 
 The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for a new 
patient visit (99203), a diagnostic dental procedure (41899), and a biopsy of the tongue (41100) provided by 
oral surgeon on December 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), panoramic radiographic 
image (D0330), and prophylaxis - adult (D1110) provided on April 19, 2022. 
 
You asked the Plan to pay for the dental services. You say that you found out after services were received that 
the provider was out-of-network. The Plan denied your request. The Plan says the dental services were received 
from an out-of-network provider and are not covered by your supplemental benefits. 
 
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 record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a periodic oral evaluation (D0120), panoramic radiographic image (D0330), and prophylaxis - adult 
(D1110) provided on April 19, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Neulasta for the enrollee. 
 
You asked the Plan to pre-approve Neulasta. You say that this is medically necessary to treat the enrollee's 
febrile neutropenia. The Plan denied your request. The Plan says that the drug/regimen is not being prescribed 
for a supported medically-accepted indication. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Neulasta. Our reviewer says that 
Neulasta is not medically reasonable and necessary. Neulasta is not FDA-approved for the enrollees diagnosis. 
The use of Neulasta is not supported by one of the major drug compendia or by clinical research that appears in 
a CMS-approved medical journal. Our physician reviewer found that the enrollee's condition does not meet 
criteria for coverage of Neulasta. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Neulasta have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Neulasta for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral periapical each radiographic image, tooth # 27 
(D0230) on January 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 January 07, 2022. 
Therefore, we decided that the Plan does not have to pay for intraoral periapical each radiographic image, tooth 
# 27 (D0230) on January 7, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says a SNF admission is not medically necessary. 
 
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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that based on the medical records provided there is no documentation that the 
enrollee requires skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled 
professional nurse are not required to safely and effectively provide medically necessary and reasonable 
treatment. The records do not document the need for intravenous medications, new tube feeding or ostomy care 
or daily complex wound care or respiratory care. This enrollee does require skilled therapy services, i.e., the 
specialized skill, knowledge and judgment of a qualified therapist are required to safely and effectively provide 
medically necessary and reasonable treatment. There is no documentation that daily skilled services are 
required. Although the records document that the enrollee is very limited functionally, the provided records do 
not document that the enrollee has the ability to participate with therapy to necessitate daily inpatient skilled 
therapy services. As a practical matter, there is no documentation that the enrollee requires the services on an 
inpatient basis, only in a skilled nursing facility setting. The records do not document that the services in the 
home or an assisted living facility with home health care or in a long-term care facility on a part time basis are 
not appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injections provided on April 12, 2022, and 
May 10, 2022. 
 
You asked the Plan to waive the coinsurance for injections. You say that you were overcharged for the 
injections. The Plan denied your request. The Plan says the coinsurance 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 20% 
coinsurance for each Medicare-covered Part B drug.  
 
You have been asked to pay $25.70 which is 20% of the allowed amount for injections. The allowed amount is 
$128.48 (20% x $128.48= $25.70). Injections fall 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 coinsurance for injections provided on April 12, 2022, and 
May 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on April 8, 
2022. 
 
You asked the Plan to waive the copayment for lab services. You say that you think the copayment should be 
waived, you say you were enrolled in this plan without your permission or knowledge. 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 $45 
copayment for each visit to a specialists office.  
 
You have been asked to pay $21.97 which is less than the standard $45 copayment for lab services. Lab 
services fall 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 laboratory services provided on April 8, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service March 10, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 76705 is bundled into payment for code 93976. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76705 billed for date of service March 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 2, 2022. 
 
You asked the Plan to pay for the lab services. You say that this should be paid for. The Plan denied your 
request. The Plan says Healthcare Common Procedure Coding System (HCPCS) code G0482 (1 Unit) remains 
not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on February 2, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) of the heart without 
contrast with quantitative evaluation of coronary calcium. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says Medicare does not cover this study for screening purposes. 
 
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 while the enrollee 
has elevated low-density lipoprotein (LDL) at 158, there are no cardiac symptoms. Medicare does not cover CT 
coronary calcium scoring as a screening test unless there is a calculated lifetime risk of greater that 9% and no 
such calculation is in the records. 
 
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) of the heart without contrast with quantitative evaluation of 
coronary calcium.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 10, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says payment for code 70450 is bundled into 
payment for code 70496. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
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 procedure code 70450 billed for date of service April 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided from November 17, 2021, to 
November 22, 2021. 
 
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says the provider is 
not a Medicare enrolled provider and as such is not eligible for reimbursement from Medicare for services 
rendered. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for dental 
services provided from November 17, 2021, to November 22, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for breast tomosynthesis (77063) provided on March 7, 2022. 
 
You asked the Plan to pay for procedure code 77063. You say that these services were pre-approved by the 
Plan. The Plan denied your request. The Plan says that they have agreed to pay for the mammogram, but code 
77063 is an add-on code which was not billed with an appropriate primary procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say that Medicare health plans 
must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision 
to deny coverage or payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, we have confirmed that code 77063 is an add-on code which is to 
be used with code 77067. The Plan did not provide the original claim as it was submitted, so we cannot verify 
how code 77063 was billed. However, in the appeal review notes and the Explanation of Benefits, the Plan 
indicates that the mammogram, which was overturned and paid by the Plan at Reconsideration, was reported 
with code 77067. This means that 77063 was billed appropriately in this case, as 77067 is an appropriate 
primary procedure for this add-on code. The Plan has provided no other reason for denial. Therefore, we 
decided that the Plan has to pay for breast tomosynthesis (77063) provided on March 7, 2022.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an external ambulatory infusion pump, insulin (E0784). 
 
You asked the Plan to pre-approve an insulin pump. You say that the enrollee has poor vision due to diabetic 
retinopathy with macular edema and the Omnipod has a larger screen than the enrollee's current pump. This 
would enable her family to assist her. The Plan denied your request. The Plan says there is no documentation 
that indicates that the enrollee's current insulin pump is not functioning or is not repairable. 
 
The Plan must follow Medicare rules. Medicare rules say carefully maintained insulin pumps should remain 
serviceable for four to seven or more years. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an insulin pump have not been met. Specifically, the enrollees current pump is not broken and still 
under warranty. Therefore, we decided that the Plan does not have to pre-approve an external ambulatory 
infusion pump, insulin (E0784).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) 
provided January 29, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment. You say that you can't believe you were 
transported to the hospital. The Plan denied your request. The Plan says this service is not covered when there 
is no transport. 
 The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on January 29, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
The trip report in this case shows that the enrollee refused transport to the hospital and thus the wavier criteria 
is not met. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, 
no transport (A0998) provided January 29, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for inpatient hospital stay provided from April 
8, 2022, to April 17, 2022. 
 
You asked the Plan to waive the cost share for inpatient hospital stay. You say that since this was COVID-19 
related the cost should be waived. The Plan denied your request. The Plan says the cost share applied is correct. 
 
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 $450 deductible which applies to Inpatient Hospital Care.  
 
The item or service you asked the Plan to waive the cost share for falls within the benefit category Inpatient 
Hospital Care. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $450 
deductible which applies to Inpatient Hospital Care. This cost sharing is a contractual obligation that had not 
been met at the time inpatient hospital stay was received on April 8, 2022, to April 17, 2022. Therefore, 
$337.33 has been applied to meet the deductible.  
 
 Since the $450 deductible was met, you have also been asked to pay $1,438.96 coinsurance. 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 the Plan does 
not have to waive the cost for inpatient hospital stay provided on April 8, 2022, to April 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve microsurgical techniques requiring the use of an 
operating microscope to be utilized during an approved spinal surgery. 
 
You asked the Plan to pre-approve the microsurgical techniques. You say that you believe that the surgery 
should be approved as requested. The Plan denied your request. The Plan says the use of microscopic 
techniques is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the microsurgical techniques. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the use of a microscope is not medically needed for a two-level lumbar 
decompression surgery. The operation may be safely performed with loupe glasses magnification.  
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 microsurgical techniques have not been met. Therefore, we decided that the 
Plan does not have to pre-approve microsurgical techniques requiring the use of an operating microscope to be 
utilized during an approved spinal surgery.