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

 
We decided that the Plan does not have to pre-approve a Rollator Walker (E1399). 
 
You asked the Plan to pre-approve a Rollator Walker. You say that the item is medically necessary. The Plan 
denied your request. The Plan says you already have a similar item. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a wheeled walker. a wheeled walker serves the same purpose as a Rollator 
Walker. Therefore, we decided that the Plan does not have to pre-approve a Rollator Walker (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for anesthesia provided on April 28, 2022. 
 
You asked the Plan to waive the deductible for anesthesia. You say that you are disputing the share cost. The 
Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $174.66 
deductible for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
You have been asked to pay $174.66 deductible for anesthesia. This item/service falls within the Outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 deductible for anesthesia provided on April 28, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zioptan drops. 
 
You asked the Plan to pre-approve Zioptan drops. You say that the enrollee's symptoms have improved and are 
stable on this drug. The Plan denied your request. The Plan says the requested drug is considered self-
administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug 
plan. The Plan also says the requested drug is not covered under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Zioptan drops.  
 Benefits for Zioptan drops may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the intraoral-
complete services of radiographic images (D0210) provided on November 8, 2022. 
 
You asked the Plan to pay for these dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the services provided 
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 services provided was exhausted on date of service September 25, 2020. 
Specifically, the Plan provides coverage for one comprehensive oral exam every three calendar years. 
Additionally, the Plan provides coverage for one panoramic/intraoral-complete series of radiographic images 
every three calendar years.   
You previously received a comprehensive oral exam and a panoramic radiographic image on September 25, 
2020, which was paid for by the Plan. Therefore, you have exhausted the allowable benefit for these services. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and 
the intraoral-complete services of radiographic images (D0210) provided on November 8, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency care visit provided on June 
23, 2022. 
 
You asked the Plan to waive the copayment for an emergency care visit. You say that you are disputing the 
share cost. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment for Emergency care. 
 
You have been asked to pay a $90 copayment for an emergency care visit. This item/service falls within the 
Emergency care benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an emergency care 
visit provided on June 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation (D4921) provided on September 20, 2022. 
 
You asked the Plan to pay for gingival irrigation. You say that no one told you that you had to wait 94 days for 
treatment. The Plan denied your request. The Plan says that gingival irrigation (D4921) is not covered by your 
supplemental dental 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for gingival 
irrigation (D4921) provided on September 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the white blood cell concentrate injection provided on May 
09, 2022. 
 
You asked the Plan to pay for the white blood cell concentrate injection. You say that the provider does not 
accept or bill to insurance. The Plan denied your request. The Plan says that unauthorized, out-of-network care 
is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the white blood cell 
concentrate injection provided on May 09, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient stay provided from October 27, 2021, to 
October 30, 2021. 
 
You asked the Plan to pay for the inpatient stay. You say that you would like this claim to be reprocessed for 
the additional payment owed. The Plan denied your request. The Plan says a request for pre-approval was not 
initiated as required by the Plan. The Plan also says without the request or granted pre-approval, post 
stabilization care after October 27, 2021, cannot be approved. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 inpatient stay. Our reviewer says that the 
inpatient stay at an out-of-network hospital was not medically reasonable and necessary for the enrollee Our 
physician reviewer found the enrollee was admitted to a non-contracted hospital and was stable for transfer to 
an in-network hospital in the emergency department following initial stabilization treatment. Our reviewer 
found that the treating physician did not document that the enrollee was not stable for transfer on any dates of 
service. Our physician reviewer also found that based on the clinical documentation available in the medical 
record the enrollee appeared stable for transfer to an in-network hospital on October 27, 2022. 
 
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 inpatient stay have not been met. Therefore, we decided that the Plan does 
not have to pay for the inpatient stay provided from October 27, 2021, to October 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a facial surgery (D7950), and a guided tissue 
regeneration (D4266 and D4267). 
 
You asked the Plan to pre-approve a facial surgery and a guided tissue regeneration. You say that you would 
like the Plan to approve these services. The Plan denied your request. The Plan says the requested dental work 
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 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 pre-approve a 
facial surgery (D7950), and a guided tissue regeneration (D4266 and D4267).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cone beam CT capture (D0367), and sedation 
(D9243). 
 
You asked the Plan to pre-approve a cone beam CT capture, and sedation. You say that these services are 
medically necessary. The Plan denied your request. The Plan says these services have been correctly denied. 
 
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, D0367 are not among those covered 
under this benefit. D9243 has been denied due to the amount of sedation that was already approved. Therefore, 
we decided that the Plan does not have to pre-approve a cone beam CT capture (D0367), and sedation (D9243).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20552 billed for date of service August 23, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the injection was medically necessary. The Plan 
denied your request. The Plan says there is a more appropriate code for the services. 
 
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 20552 is injection(s); single or multiple trigger point(s), 1 
or 2 muscle(s). We find that CPT code 20552 is not supported in the medical record. The records show that the 
enrollee received an epidural steroid injection. There is a more comprehensive code available that better 
describes the service provided.  Based on this information, we decided that Medicare rules for coverage of the billed services have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 20552 billed for date of 
service August 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for Medicare Part B prescription drugs, 
laboratory services and outpatient surgery provided on November 11, 2022. 
 
You asked the Plan to waive the cost share for Medicare Part B prescription drugs, laboratory services and 
outpatient surgery. You say that you disagree with the cost share. The Plan denied your request. The Plan says 
this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Medicare Part B prescription drugs a $2 copayment for outpatient hospital services/lab service and a $350 copayment for outpatient surgery.  
 
You have been asked to pay a 20% coinsurance for Medicare Part B prescription drugs a $2 copayment for 
laboratory services and a $350 copayment for outpatient surgery. The total allowed amount for the prescription 
drugs $165.57. The amount you are being asked to pay for the prescription drugs is $33.12 ($165.57 x 20% = 
$33.12). The amount you are being asked to pay $233.21 for the outpatient surgery which is less than the 
required amount. The total amount you are being asked to pay for all services is $268.33 ($33.12 + $233.21 
+$2 = $268.33). 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 Medicare Part B prescription 
drugs, laboratory services and outpatient surgery provided on November 11, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and psychotherapy provided on April 25, 
2022, by an OON provider. 
 
You asked the Plan to pay for an office visit and psychotherapy. You say that you were not told that the 
provider was out-of-network. The Plan denied your request. The Plan says you must receive your care from a 
network provider. 
 
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 an office visit and psychotherapy provided on 
April 25, 2022, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services billed under codes 88305 and 88312 
provided on September 15, 2022. 
 
You asked the Plan to pay for laboratory services billed under codes 88305 and 88312. You say that you are 
appealing the claim payment denial. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory services 
billed under codes 88305 and 88312 provided on September 15, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiofrequency ablation (64625) provided on September 
2, 2022. 
 
You asked the Plan to pay for the radiofrequency ablation. The Plan denied your request. The Plan says this 
service is not covered by Medicare. 
 
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 pay for the radiofrequency ablation. Our reviewer 
says that the radiofrequency ablation is not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is considered an experimental/investigational approach because of the wide 
variation in efficacy reported in the literature. 
 
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 radiofrequency ablation have not been met. Therefore, we decided that the 
Plan does not have to pay for the radiofrequency ablation (64625) provided on September 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and suspension 
sleeve (E0673), provided on August 30, 2022. 
 
You asked the Plan to pay for a pneumatic compression device and suspension sleeve. You say that the item 
was medically necessary. The Plan denied your request. The Plan says this item was used in a surgical center. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that a pneumatic compression device and suspension sleeve was used in a SNF or hospital. 
Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675) and 
suspension sleeve (E0673), provided on August 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic-porcelain fused to high noble metal (D6240 x5) 
for tooth #18, #19, #28, #30, and #31 and a retainer crown-porcelain fused to high noble metal (D6750 x4) for 
tooth #17, #20, #27, and #32. 
 
You asked the Plan to pre-approve the dental services. You say that you do not agree with the determination 
made by the Plan. You say you need these services for your health, and you chose the Plan to help you with 
your dental work. The Plan denied your request. The Plan says the dental services were denied because the x-
rays received do not match the requested tooth and or area. The Plan upheld the initial denial as the x-rays sent 
originally do not match the ones sent later. 
 
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 pontics and 
retainer crowns 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 the pontics and retainer crowns. Our 
reviewer says that the treatment requested is not medically necessary. Teeth #17, 20, 27 and 32 all are 
periodontally involved, with less than 50% bone support remaining. These teeth are not suitable for being 
abutment teeth, particularly with the long spans that are being suggested. There should be at least a 1:1 crown 
to root ration, and more so in long span bridges as the ones suggested. The placement of bridges on these teeth 
will result in rapid failure of the remaining abutment teeth and would not be considered reasonable or 
necessary. Another type of treatment should be considered. 
 
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 pontic and a retainer crown have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a pontic-porcelain fused to high noble metal (D6240 x5) for tooth #18, #19, 
#28, #30, and #31 and a retainer crown-porcelain fused to high noble metal (D6750 x4) for tooth #17, #20, #27, 
and #32.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the abdomen 
before and after contrast. 
 
You asked the Plan to pre-approve the MRI. You say that the MRI is medically necessary. The Plan denied 
your request. The Plan says the enrollee had an MRI less than 24 months prior to the new request. 
 
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 MRI. Our reviewer says that the 
MRI of the abdomen is not medically necessary. Our physician reviewer found that per eviCore standard-of-
care imaging guidelines (eviCore.com) "Pancreatic Cystic Lesions" AB-31.1, those identified per MRI 
November 21, 2021, were all under 1 cm and without high-risk features (e.g., intraductal papillary mucinous 
neoplasms (IPMN) with new onset or worsening diabetes, rapid increase in cyst size during surveillance, 
significant elevation in carbohydrate antigen 19-9, pancreatic duct dilation, jaundice secondary to the cyst, 
IPMN's greater than 3 cm). The enrollee meets none of these high-risk features, and as such warrants a repeat 
magnetic resonance cholangiopancreatography at a 2-year interval. The requested time frame is too soon per 
eviCore guidance and based on available records is not due until November of 2023. 
 
  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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a magnetic resonance imaging (MRI) of the abdomen before and after contrast.