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

 
We decided that the Plan does not have to pre-approve radiopharmaceutical localization of a tumor (78801). 
 
You asked the Plan to pre-approve radiopharmaceutical localization of a tumor. You say that this is medically 
reasonable and necessary. The Plan denied your request. The Plan says the requested testing is not medically 
reasonable and 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 radiopharmaceutical localization of a 
tumor. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found at issue is the medical appropriateness and necessity of 
Single-photon emission computed tomography (SPECT) imaging in the clinical evaluation of this patient. The 
records do not show evidence of ATTR (amyloid transthyretin). There is no clinical evidence provided to 
support the performance of SPECT imaging in this patient according to current guidelines. As a result, at this 
time SPECT imaging would not be considered medically reasonable and necessary in this patients clinical 
management. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiopharmaceutical localization of a tumor have not been met. Therefore, we 
decided that the Plan does not have to pre-approve radiopharmaceutical localization of a tumor (78801).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
April 14, 2021, to April 16, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the DRG was updated.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 330 (MAJOR SMALL AND LARGE 
BOWEL PROCEDURES WITH CC). We asked our physician reviewer to carefully review the case file and 
apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the 
services. Our reviewer says that the services at issue in this case were not supported by the medical records. 
Our physician reviewer found the patient had hyponatremia preoperatively (130) and was given fluids, blood 
transfusion and later the sodium normalized (137). The cause of the hyponatremia was not described in the 
provided records, nor was there report of it was directly treated. There were no other clinical complications or 
comorbidities from this admission that would justify the DRG 330. The DRG 331 (MAJOR SMALL AND 
LARGE BOWEL PROCEDURES WITHOUT CC/MCC), however, would be most appropriate.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from April 14, 2021, to April 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the foot amputation (28805) provided by a surgical assistant 
on August 12, 2021. 
 
You asked the Plan to pay for the foot amputation (28805). You say that the primary surgeon requested 
services from an assistant surgeon in the best interest of the patient. You say that the surgical assistant could 
not deny the services to the patient, and you are appealing the denial. The Plan denied your request. The Plan 
says Medicare does not pay for assistant surgeon services when provided by a Licensed Surgical Assistant. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
  In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for the foot amputation (28805) 
provided by a surgical assistant on August 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MRA, head; without contrast material(s), followed by 
contrast material(s) and further sequences (CPT code 70546) and MRA, neck; without contrast material(s), 
followed by contrast material(s) and further sequences (CPT code 70549). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the medical records indicate there is no known or suspected carotid artery stenosis 
(narrowing of the blood vessels), neck trauma, pre-or post-operative planning for carotid endarterectomy 
(procedure to treat carotid artery disease), or vertebral artery stenosis (condition of plaque buildup) or 
occlusion (blockage or closing of a blood vessel). 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our physician reviewer 
found the medical records indicate there is no known or suspected carotid artery stenosis (narrowing of the 
blood vessels), neck trauma, pre-or post-operative planning for carotid endarterectomy (procedure to treat 
carotid artery disease), or vertebral artery stenosis (condition of plaque buildup) or occlusion (blockage or 
closing of a blood vessel) to justify this request. There are no pulmonary embolism (PE) findings that included 
suspicion of blockage such as bruit. Therefore, without sufficient support made, MRA will be considered not 
medically necessary based on the provided documentation. 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve MRA, head; without contrast material(s), followed by contrast material(s) and further 
sequences (CPT code 70546) and MRA, neck; without contrast material(s), followed by contrast material(s) 
and further sequences (CPT code 70549).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Zinger chair. 
 
You asked the Plan to pre-approve these services. You say that this is necessary for you. The Plan denied your 
request. The Plan says that this provider is not a Medicare certified DME provider. 
 
The rules state that Medicare payment cannot be made to a supplier who is not enrolled in the Medicare 
Program. 
 
This item is not being provided by a supplier who is enrolled in the Medicare program. Therefore, we decided 
that the Plan does not have to pre-approve a Zinger chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140), and fillings (D2330, 
D2331) provided on March 3, 2022, by the out of network dentist. 
 
You asked the Plan to pay for the dental services. You say that your regular dentist could not get you in for 
almost 5 weeks. You say that you went to your previous dentist as a result. You also say that you expect to be 
reimbursed whatever amount would have been reimbursed to your regular dentist. The Plan denied your 
request. The Plan says dental services received out of network are not covered. 
 
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, dental services received out of network 
are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
the limited oral evaluation (D0140), and fillings (D2330, D2331) provided on March 3, 2022, by the out of 
network dentist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the endodontic therapy, premolar 
tooth (excluding final restoration) (D3320) provided November 22, 2021, by an out-of-network (OON) 
provider. 
 
You asked the Plan to provide additional payment for the root canal. You say that you were told by the Plan 
and the provider that the provider was in-network. The Plan denied your request. The Plan says the claim has 
processed correctly according to your OON dental benefits. Additionally, the Plan says that they have checked 
the call log and found that no misinformation was provided. 
 
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 the root canal 
with 50% coinsurance. You may be billed for charges above what the Plan pays for services provided OON. We looked at the file and Medicare rules. The Plan provided documentation showing that you have been asked 
to pay 50% of the Plans allowed amount for this service. Additionally, you are responsible for the difference 
between the Plans allowed amount and the total cost billed by the OON provider. Therefore, we decided that 
the Plan does not have to provide additional payment for the endodontic therapy, premolar tooth (excluding 
final restoration) (D3320) provided November 22, 2021, by an out-of-network (OON) provider.  
 
Your complaint about potentially receiving misinformation from the Plan about the providers network status 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the progressive lenses (V2781) provided on December 8, 
2021. 
 You asked the Plan to pay for progressive lenses. You say that you would like reimbursement for these lenses. 
The Plan denied your request. The Plan says this item is not covered by Medicare or by your health plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we 
decided that the Plan does not have to pay for the progressive lenses (V2781) provided on December 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from June 
9, 2021, to June 17, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the DRG for this inpatient admission was reassigned.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 193 (SIMPLE PNEUMONIA AND 
PLEURISY WITH MCC). We asked our physician reviewer to carefully review the case file and apply the 
relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our 
reviewer says that the services at issue in this case were not supported by the medical records. Our physician 
reviewer found the enrollee was diagnosed with pneumonia and urinary tract infection, and treated with 
antibiotics and fluids. Her mental status was described as at baseline and was alert and oriented to person but 
answered some questions incorrectly. There was no clear description of signs or symptoms that would meet the 
definition of metabolic encephalopathy during this hospital stay. Therefore, the DRG 194 (SIMPLE 
PNEUMONIA AND PLEURISY WITH CC) would be most appropriate for this admission.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from June 9, 2021, to June 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the online meditation classes provided from 
February 1, 2021, to October 31, 2021. 
 
You asked the Plan to reimburse you for the wellness services. You say that the Wellness Wallet covers a wide 
range of eligible indoor and outdoor fitness equipment, classes, membership fees, and 
acupuncture/naturopathy. You say that these services should be covered as they help with your anxiety and 
depression. The Plan denied your request. The Plan says mediation cannot be covered under the Wellness 
Wallet as it does not fall under any of the CMS-approved categories. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the wellness services have not been met. Therefore, we decided that the Plan does not have to 
reimburse you for the online meditation classes provided from February 1, 2021, to October 31, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse extended warranty agreement (A9270) purchased January 
7, 2022. 
 
You asked the Plan to reimburse extended warranty agreement. You say that you believe the decision should be 
reversed. This annual charge of $195.00 per year is an integral part of having the stimulator work in your back. 
The Plan denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Enrollee opted to extend the one-year manufacturers warranty 
through the purchase of an extended service agreement. Enrollee is not required to purchase this voluntary 
offer. Based on this information, we decided that Medicare rules for coverage of extended warranty agreement 
have not been met. Therefore, we decided that the Plan does not have to reimburse extended warranty 
agreement (A9270) purchased January 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that the requested procedure is medically 
necessary. The Plan denied your request. The Plan says the requested Vertiflex procedure is considered 
experimental/investigational. 
 
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 Vertiflex procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex device is experimental. More research is needed before coverage can be 
approved. 
 
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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) 
provided February 9, 2022. 
 
You asked the Plan to pay for the core buildup. You say that you don't feel this service was provided. The Plan 
denied your request. The Plan says this service is 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 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 the core 
buildup, including any pins when required (D2950) provided February 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the eye exam services (92014, 92134) 
provided on December 6, 2021. 
 
You asked the Plan to waive the copayment for the eye exam services. You say that you were unable to attend 
this follow-up appointment within 90 days of your surgery, and this should be covered in full. The Plan denied 
your request. The Plan says this claim was processed correctly, and your copayment was assessed in 
accordance with your contract. 
 
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 $35 
copayment for Medicare-covered vision services provided in a specialist's office.  
 
You have been asked to pay a $35 copayment for the eye exam services. The services provided fall within the 
Medicare-covered vision services provided in a specialist's office 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 the eye exam services (92014, 
92134) provided on December 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection, of diagnostic or therapeutic substances 
(anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including 
needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic (62320) provided 
November 1, 2021. 
 
You asked the Plan to pay for the injection services. You say that you are appealing the Plan's decision to deny 
payment. The Plan denied your request. The Plan says there is insufficient documentation and medical 
necessity cannot be established. 
 The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the injection, of diagnostic or 
therapeutic substances (anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic 
substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic 
(62320) provided November 1, 2021. have been met. the records provided are undated and unsigned. The Plan 
had made multiple attempts to obtain clinical records to support the medical necessity of the services without 
success. Therefore, we decided that the Plan does not have to pay for the injection, of diagnostic or therapeutic 
substances (anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, 
including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic (62320) 
provided November 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for occupational therapy services provided by an occupational 
therapy assistant on June 19, 2020. 
 
You asked the Plan to pay for occupational therapy services. You say that medical records required to 
reprocess the denied claim are attached. The Plan denied your request. The Plan says the code is not 
appropriate for the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the services of an occupational therapy assistant 
(OTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, 
because they do not meet the qualifications of a therapist. 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of occupational therapy services have not been met. Specifically, the billing provider is a nurse 
practitioner, and not a licensed therapist. As such, OTA services cannot be paid incident to this provider's 
professional services. Therefore, we decided that the Plan does not have to pay for occupational therapy 
services provided by an occupational therapy assistant on June 19, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 home test kit provided on January 19, 2022. 
 
You asked the Plan to pay for the COVID-19 home test kit. You say that you thought the at home COVID-19 
tests would be covered because the pharmacy told you that you would be reimbursed by your insurance 
company. You also say that you would like to be reimbursed $39. The Plan denied your request. The Plan says 
your claim for the at-home COVID-19 test denied correctly. The Plan also says that at this time, Medicare has 
not announced an expansion of over-the-counter testing coverage for Medicare or Special Needs Plans, 
meaning Original Medicare is not currently covering at-home COVID-19 tests. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare will only pay for claims with dates of 
service starting on or after April 4, 2022, through the last day of the COVID-19 public health emergency 
(PHE), and claims should be submitted to Original Medicare for patients enrolled in a Medicare Advantage 
(MA) plan.  
 
 
  We looked at the file and Medicare rules. Over the counter (OTC) tests for dates of service April 4, 2022 and 
after are paid for. OTC tests before April 4, 2022 are only covered if the Plan has a supplemental benefit for 
them. Centers for Medicare & Medicaid Services (CMS) instructs that for a Medicare Advantage beneficiary, 
the claim for the test should be submitted to Original Medicare instead of the Plan. Based on this information, 
we decided that Medicare rules for coverage of the COVID-19 home test kit have not been met. Therefore, we 
decided that the Plan does not have to pay for the COVID-19 home test kit provided on January 19, 2022.