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

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on July 29, 
2022. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the 
copayment. 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 $255 
copayment for ambulance services.  
 
You have been asked to pay a $255 copayment for ambulance services. However, you are only being asked to 
pay $236.62 which is less than the required amount. This item/service falls within the ambulance services 
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 ambulance services provided on 
July 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar 
spine. 
 
You asked the Plan to pre-approve the MRI. You say that it is medically necessary for the enrollee to get the 
MRI done. The Plan denied your request. The Plan says the enrollee has not responded to at least 6 weeks of 
conservative management; therefore, the MRI is not medically necessary. 
 
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 lumbar spine is not medically necessary. Our physician reviewer found that during the enrollee's 
yearly wellness exam of October 19, 2022, their neuro exam was negative. Lumbar spine x-rays on October 19, 
2022, showed multilevel degenerative changes and a chronic pars defect at L5-S1. There are no red flags 
documented which preclude a supervised and monitored 6-week trial of physical therapy before an MRI can be 
approved. Medical necessity of the requested MRI of the lumbar spine has not been established in the 
submitted 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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the placement of Superion Vertiflex spinous process 
spacer (22869 and 22870). 
 
You asked the Plan to pre-approve the placement of Superion Vertiflex spinous process spacer. You say that 
the services are medically necessary. The Plan denied your request. The Plan says the services are 
experimental. 
 
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 placement of Superion Vertiflex 
spinous process spacer. Our reviewer says that the requested services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found current evidence based medical guideline and peer 
reviewed literature do not fully support the spinal decompression device procedure over the gold standard of 
lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the 
use of this device for this enrollees medical condition as discussed above. 
 
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 placement of Superion Vertiflex spinous process spacer have not been 
met. Therefore, we decided that the Plan does not have to pre-approve the placement of Superion Vertiflex 
spinous process spacer (22869 and 22870).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation - established patient (D0120), 
resin-based composite - one surface, anterior (D2330), prophylaxis - adult (D1110), and bitewings - four 
radiographic images (D0274) provided on September 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are requesting reconsideration because of a 
conversation you had with the Plan's customer service representative on September 30, 2022. 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 - established patient (D0120), resin-based composite - one surface, anterior 
(D2330), prophylaxis - adult (D1110), and bitewings - four radiographic images (D0274) provided on 
September 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the therapeutic continuous glucose monitor (CGM). You say that this should 
be covered because the Evidence of Coverage states there is coverage for continuous glucose monitors. The 
Plan denied your request. The Plan says you do not require insulin three or more times daily. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the therapeutic continuous glucose monitor 
(CGM) and supplies. have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
therapeutic continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedures codes 88341 and 88342 billed for date of service 
April 5, 2022. 
 You asked the Plan to pay for procedure codes 88341 and 88342. You say that there is no conflict with the 
billed codes. The Plan denied your request. The Plan says payment for codes 88341 and 88342 are bundled into 
payment for code 88361. 
 
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 codes 88341 and 88342 are column II codes to column I code 88361. The 
codes at issue have not been billed with an appropriate modifier to bypass the edit. Based on the claim 
submitted, the Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for procedures codes 88341 and 88342 billed for date of service April 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulation supplies provided on June 11, 2022. You asked the Plan to pay for the billed services. You say that this is an acceptable procedure code. The Plan 
denied your request. The Plan says the documentation does not sufficiently support the billed supply code. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order or relevant medical records which support medical 
necessity for the supplies provided in this case. Based on this information, we decided that the Medicare rules 
for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the electrical 
stimulation supplies provided on June 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on July 1, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that there is no agreement that the codes billed 
are included in the dialysis rate. The Plan denied your request. The Plan says Medicare does not separately pay 
for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable.  
 
 
 Laboratories should bill the facility directly for laboratory services as they are considered part of the composite 
rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay 
for the laboratory services related to end-stage renal disease (ESRD) provided on July 1, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) of abdomen and pelvis 
(74177) provided on February 24, 2022. 
 
You asked the Plan to pay for the CT. You say that the service was medically necessary. The Plan denied your 
request. The Plan says the enrollees claim would be covered under Original Medicare as it is responsible for 
coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is 
revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering 
services and to know proper billing procedures for a Medicare Advantage member on hospice.  
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the computed tomography (CT) of abdomen and pelvis 
(74177) provided on February 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite - one surface, posterior tooth #18 
(D2391) provided on September 20, 2022. 
 
You asked the Plan to pay for the resin-based composite - one surface, posterior tooth #18 (D2391). You say 
that you disagree with the denial and would like the Plan to reconsider payment. The Plan denied your request. 
The Plan says this service is not covered under the benefit package. 
 
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 a resin-
based composite - one surface, posterior tooth #18 (D2391) provided on September 20, 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 the removal of 
bone and/or sectioning of tooth (D7210) for teeth numbers 3, 6, 7, 8, 9, 10, 11, 12, 13, and 14, an alveoloplasty 
in conjunction with extractions (D7310) for the upper left and upper right quadrants, a consultation for a 
diagnostic services provided by a dentist or physician other than the requesting dentist or physician (D9310), 
and an unspecified adjunctive procedure (D9999) provided on October 13, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were not aware of the "out-of-network" 
until you started to file a claim. 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 an extraction of an erupted tooth requiring the removal of bone and/or sectioning of tooth (D7210) 
for teeth numbers 3, 6, 7, 8, 9, 10, 11, 12, 13, and 14, an alveoloplasty in conjunction with extractions (D7310) 
for the upper left and upper right quadrants, a consultation for a diagnostic services provided by a dentist or 
physician other than the requesting dentist or physician (D9310), and an unspecified adjunctive procedure 
(D9999) provided on October 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on May 27, 2022, 
and a periodic oral evaluation (D0120) and bitewing x-rays (D0274) provided on August 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that you always call your dental provider to make 
sure your services will be covered. The Plan denied your request. The Plan says your benefit for the requested 
items or services 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 a limited oral evaluation was exhausted on date of service June 9, 2022. The record also 
shows your benefit for a periodic oral evaluation was exhausted on date of service February 11, 2022, and July 
11, 2022. The record also shows your benefit for a bitewing x-ray was exhausted on date of service February 
11, 2022. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on May 27, 2022, and a periodic oral evaluation (D0120) and bitewing x-rays (D0274) provided on 
August 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Aflibercept injection (J0178) provided 
on October 4, 2022. 
 
You asked the Plan to waive the coinsurance for the Aflibercept injection. You say that the 2022 manual states 
there is a $0 copay for Medicare-covered exams to diagnose and treat diseases and conditions of the eye for 
vision care. You also say that this injection was for the treatment of macular degeneration, and your cost share 
should be $0. 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.  
 
You have been asked to pay a 20% coinsurance for the Aflibercept injection. 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 coinsurance for 
the Aflibercept injection (J0178) provided on October 4, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay provided from 
September 1, 2022, through September 9, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you are disputing the 
amount of the copayment and would like the claim reprocessed without member responsibility. 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 $125 
copayment per day, days 1-10 and $0 copayment per day, starting with day 11.  
 
You have been asked to pay $1,000 for inpatient hospital stay ($125/day x 8 = $1,000). This inpatient hospital 
stay falls within the Inpatient hospital 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 inpatient hospital stay provided from September 1, 2022, through September 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a medical eye examination (92014) and a determination of 
refractive state (92015) provided on June 20, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a medical eye examination (92014) and a determination of refractive state 
(92015). You say that you are an in-network provider. The Plan denied your request. The Plan says the 
member's plan excludes coverage for this out-of-network service. 
 
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 a medical eye examination (92014) and a 
determination of refractive state (92015) provided on June 20, 2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of carboplatin, gemcitabine, and bevacizumab. 
 
You asked the Plan to pre-approve carboplatin, gemcitabine, and bevacizumab. You say that this would be a 
good treatment for the enrollee. The Plan denied your request. The Plan says this is not approved or supported 
for the requested use. 
 
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 carboplatin, gemcitabine, and 
bevacizumab. Our reviewer says that the enrollee does not meet the criteria for the requested chemotherapy 
regimen. Our physician reviewer found this regimen is not Food & Drug Administration (FDA) approved for 
the enrollee's diagnosis. These drugs are not supported by one of the major drug compendia or by clinical 
research appearing in a Medicare-approved medical journal. For progression, single agent therapy is 
recommended.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of carboplatin, gemcitabine, and bevacizumab have not been met. Therefore, we 
decided that the Plan does not have to pre-approve use of carboplatin, gemcitabine, and bevacizumab.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate for spinal surgery. 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that this treatment plan would serve the 
enrollee best. The Plan denied your request. The Plan says studies have not shown that this procedure is 
helpful. 
 
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 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 bone marrow aspirate is experimental, more research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate for spinal surgery.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97530 billed for date of service March 4, 
2022. 
 
You asked the Plan to pay for procedure code 97530. You say that the documentation supports the claim. The 
Plan denied your request. The Plan says payment for code 97530 is bundled into payment for code 92526. 
 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 97530 is a column II code to column I code 92526. 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 97530 
billed for date of service March 4, 2022.