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

 
We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (DNA OR 
RNA); candida species, amplified probe technique (87481) provided December 6, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that this test is medically necessary for the 
management of this enrollee's treatment of onychomycosis. The Plan denied your request. The Plan says 
service is not documented in the medical records. 
 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 laboratory service. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was examined and diagnosed with onychomycosis. However, testing is 
typically not needed for diagnosis as clinical presentation and physical examination is often sufficient for 
diagnosis and the provided documentation did not suggest a confusion presentation or atypical physical 
findings to warrant testing. Also, the remaining treatment options for this enrollee would be considered 
regardless of the PCR results. It was not clear how the PCR testing would lead to an improved outcome for this 
enrollee. Therefore, the PCR infectious agent detection will be considered not medically necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for the infectious agent detection by nucleic acid (DNA OR RNA); candida species, 
amplified probe technique (87481) provided December 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lodging and transportation related services provided out-of-
area from October 11, 2021, to May 31, 2022. 
 
You asked the Plan to pay for lodging and transportation related services. You say that the Plan's denial is 
unclear. You say that the ultimate goal of treatment in both Seattle and Houston was stem cell transplant. The 
Plan denied your request. The Plan says they verified with the facility in Seattle that the treatment provided was 
not transplant related. The Plan says that only evaluation date for transplant related services they were able to 
verify had taken place was in Houston on February 16 and February 17, 2022. The Plan says that they only 
provide payment for applicable lodging and travel expenses that were incurred on or after the evaluation date 
for transplant related services. 
 
The Plan must follow Medicare rules. Medicare rules say that MA plans must provide reasonable transportation 
and accommodations for an enrollee and companion while in a distant location for transplant services. 
Medicare rules also 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. The Plan states that they confirmed that there was no evaluation for 
transplant services performed until February 16 and February 17, 2022. Medicare only requires coverage of 
transportation and accommodations while an enrollee is at a distant location for transplant services. The only 
information you supplied was receipts of payment for lodging and transportation services. Without medical 
records, we are unable to verify that the out-of-area services provided during the span of dates in dispute was 
transplant related. Based on this information, we decided that there is insufficient information in the record to 
determine if Medicare rules for coverage of lodging and transportation services have been met. In addition, the 
services which remain unpaid for the dates of service after the confirmed transplant evaluation on February 16 
and February 17, 2022, were for a $100 deposit and for an $85 cleaning fee. The receipt provided shows that 
the security deposit is refundable from the location that you stayed. A cleaning fee is not a covered benefit 
under Medicare. Therefore, we decided that the Plan does not have to pay for lodging and transportation related 
services provided out-of-area from October 11, 2021, to May 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) provided on August 16, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit by the 
Plan or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99213) provided on August 16, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional thirty (30) trips to be provided by an out-
of-network ambulance provider. 
 
You asked the Plan to pre-approve the out-of-network ambulance services. You say that the enrollee needs to 
get dialysis. The Plan denied your request. The Plan says there is an in-network provider that can perform the 
services the enrollee needs. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an additional thirty (30) trips to be provided by an out-of-network ambulance provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the periodontal maintenance (D4910) provided on 
August 16, 2022. 
 
You asked the Plan to pay more for the dental service. You say that you would like the Plan to fully cover the 
dental service. The Plan denied your request. The Plan says you are responsible for any charged amount above 
the Plans cost-sharing amount when your services are received from an out-of-network provider. 
 
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. 
 
  You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for the periodontal maintenance (D4910) 
provided on August 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral - complete series of radiographic images 
(D0210) and a topical application of fluoride varnish (D1206) provided on August 10, 2022. 
 
You asked the Plan to pay for an intraoral - complete series of radiographic images (D0210) and a topical 
application of fluoride varnish (D1206). You say that you called the Plan and asked if this provider was in-
network and the Plan said they were. The Plan denied your request. The Plan says according to the EOC, there 
is no coverage for full mouth x-ray or topical application of fluoride vanish. 
 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 an 
intraoral - complete series of radiographic images (D0210) and a topical application of fluoride varnish 
(D1206) provided on August 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction of an erupted tooth requiring removal of bone 
and/or sectioning of tooth (D7210) for extractions 3 through 15 provided on June 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not aware that the pre-operative x-ray 
was necessary in order to process this claim. You also say that you are submitting that with your appeal. 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 June 15, 2022, with this 
service. Therefore, we decided that the Plan does not have to pay for an extraction of an erupted tooth requiring 
removal of bone and/or sectioning of tooth (D7210) for extractions 3 through 15 provided on June 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup, including any pins when required (D2950) 
provided on January 12, 2022. 
 
You asked the Plan to pay for the core buildup, including any pins when required (D2950). You say that you 
tried using the CarePlus card with an allowance and was unable to. You also say that you would like to have 
the $250.00 reimbursed. The Plan denied your request. The Plan says this service is not covered under the 
benefit package. The Plan also says that the pre-loaded allowance card provided to you can be used to pay out-
of-pocket for covered preventative and comprehensive dental, vision, and hearing services at participating 
providers. 
 
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 core 
buildup, including any pins when required (D2950) provided on January 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve fluoride gel carrier (D5986). 
 
You asked the Plan to pre-approve the dental service. You say that you are appealing the denied dental service. 
The Plan denied your request. The Plan says the denial of authorization for this service is correct, because 
fluoride gel carrier is not covered by the Plan. 
 
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 
fluoride gel carrier (D5986).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for the intravitreal injection of a 
pharmacologic agent (67028) and injection, aflibercept (J0178) provided on May 17, 2022. 
 
You asked the Plan to waive the cost-sharing for the aflibercept injection into the eye. You say that you should 
not be responsible for this 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 20% 
coinsurance for Medicare-covered Part B drugs.  
 You have been asked to pay 20% coinsurance for the aflibercept injection into the eye. This item/service 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 cost-sharing 
for the intravitreal injection of a pharmacologic agent (67028) and injection, aflibercept (J0178) provided on 
May 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you the entire amount of the grocery items purchased at a 
store on September 25, 2022. 
 
You asked the Plan to reimburse you for grocery items purchased at a store. You say that you are on a fixed 
income, and the card would not go through. The Plan denied your request. The Plan says per your EOC, if the 
costs of the approved personal care and grocery items exceeds the benefit limit of $70 per calendar quarter, you 
are responsible for all additional costs. 
 
Medicare generally does not cover over-the-counter services. However, the Plan offers an over-the-counter 
benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case.   Though the Plan offers an over-the-counter benefit in excess of Medicare coverage, certain limitations apply. 
The Plan rules say they will cover $70 per calendar quarter for the personal care and grocery items. The Plan 
rules also say that you are responsible for all additional costs. The record shows your benefit for the requested 
item or service was exhausted on this date of service. Therefore, we decided that the Plan does not have to 
reimburse you the entire amount of the grocery items purchased at a store on September 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services (D7450 and D7285). 
 
You asked the Plan to pre-approve the dental services (D7450 and D7285). You say that you would like to 
request reconsideration of the denied authorization. The Plan denied your request. The Plan says the dental 
services (D7450 and D7285) 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 the 
dental services (D7450 and D7285).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bone marrow aspirate (20939). 
 
You asked the Plan to pre-approve the bone marrow aspirate. You say that the service is necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of bone marrow aspirate in the setting of 
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 the bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no specific indication provided 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. Therefore, the requested bone marrow aspirate in the setting of spinal fusion surgery, in this case, is not medically reasonable or necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the bone marrow aspirate have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the bone marrow aspirate (20939).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the biologic materials to aid in tissue regeneration 
(D4265), the guided tissue regeneration (D4266), the bone graft for ridge preservation (D7953). 
 
You asked the Plan to pre-approve the biologic materials to aid in tissue regeneration (D4265), the guided 
tissue regeneration (D4266), and the bone graft for ridge preservation (D7953). You say that you are appealing 
the denial. The Plan denied your request. The Plan says the services 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 biologic materials to aid in tissue 
regeneration (D4265), the guided tissue regeneration (D4266), and the bone graft for ridge preservation 
(D7953) are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pre-approve the biologic materials to aid in tissue regeneration (D4265), the guided tissue regeneration 
(D4266), the bone graft for ridge preservation (D7953).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services (87186) provided on September 14, 2021. 
 
You asked the Plan to pay for procedure code 87186. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for procedure code 87186 by a contract provider. The file does not show that the plan 
provided notice that procedure code 87186 would not be covered. Under Medicare rules, this means procedure 
code 87186 is considered approved by the plan. Therefore, we decided that the Plan has to pay for the 
laboratory services (87186) provided on September 14, 2021.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician standby services (99360) provided July 22, 
2022 
 
You asked the Plan to pay for the physician standby services. You say that you do not agree with the denial for 
medical necessity. You have provided documentation to show medical necessity as the surgeon believed 
monitoring services were needed at the time of procedure. 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 In this case, the CPT Code Manual definition of code 99360 is physician standby service, requiring prolonged 
physician attendance, each 30 minutes (eg, operative standby, standby for frozen section, for cesarean/high risk 
delivery, for monitoring EEG). 
 
We find that CPT code 99360 is not supported in the medical record. Specifically, standby services are not 
payable to physicians. Physicians may not bill Medicare or beneficiaries for standby services. Payment for 
standby services is included in the Part A payment to the facility. Such services are a part of hospital costs to 
provide quality care. If hospitals pay physicians for standby services, such services are part of hospital costs to 
provide quality care. Based on this information, we decided that Medicare rules for coverage of the physician 
standby services have not been met. Therefore, we decided that the Plan does not have to pay for the physician 
standby services (99360) provided July 22, 2022
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care following the back fusion surgery. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the stay is necessary. The Plan denied 
your request. The Plan says the enrollee's records do not indicate that they have comorbid illness which may 
require a brief stay extension for relevant monitoring, treatment, and/or consultation. The Plan states this 
surgery is not on the Medicare inpatient only list. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the medical records do not indicate that the enrollee has any comorbid illness which 
may require a brief stay extension for relevant monitoring, treatment, and/or consultation. This surgery is not 
on the Medicare inpatient only list. There is no medical indication for an inpatient hospital admission for the 
elective procedure. The review has determined that the record does not show that the inpatient hospital care is 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient hospital care following the back fusion surgery.