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

 
We decided that the Plan does not have to pay for procedure code 70480 billed for date of service April 16, 
2022. 
 
You asked the Plan to pay for procedure code 70480. You say that the services were medically necessary. The 
Plan denied your request. The Plan says payment for code 70480 is bundled into payment for code 70450. 
 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 70480 
is a column II code to column I code 70450. 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 70480 billed for date of service April 16, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the continuous glucose monitor (CGM) supplies provided on 
November 3, 2021. 
 
You asked the Plan to pay for the CGM supplies. 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. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan argues that there was no claims history found to show that a face-to-
face encounter occurred to support the services as billed. A face-to-face encounter is an in-person or telehealth 
encounter between the treating practitioner and the beneficiary. The file shows that there are progress notes 
from a visit with the treating physician on September 30, 2021. As this is the only rationale the Plan has 
provided for denial of payment, we find that the Plan has not substantiated their reasoning for denial based on 
Medicare guidelines. Therefore, we decided that the Plan has to pay for the continuous glucose monitor (CGM) 
supplies provided on November 3, 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 skilled nursing facility (SNF) services provided 
September 12, 2020, to September 30, 2020. 
 
You asked the Plan to pay for the SNF services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the documentation does not support the services billed. 
 
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. 
 
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 SNF services. Our reviewer says that the 
documentation does not support the services billed. Our physician reviewer found the documentation does not 
support that nursing function score was less than or equal to 11. The documentation indicates that the Special 
Care Low category with a diagnosis of Parkinsons is not supported by the 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 SNF services have not been met. Therefore, we decided that the Plan does 
not have to pay for the skilled nursing facility (SNF) services provided September 12, 2020, to September 30, 
2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Euflexxa. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has pain related to osteoarthritis of the right knee, diagnosis confirmed with imaging studies. 
The enrollee has failed conservative treatment. The documentation does not support that the enrollee has tried 
and failed Orthovisc or Supartz FX. The documentation does not include an indication that Orthovisc or 
Supartz FX would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic parenteral drugs, two or more 
administrations, different medications (D9612) and removal of torus mandibularis (D7473). 
 
You asked the Plan to pre-approve therapeutic parenteral drugs and removal of torus mandibularis. You say 
that you would like these services covered. The Plan denied your request. The Plan says these services are 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 pre-approve 
therapeutic parenteral drugs, two or more administrations, different medications (D9612) and removal of torus 
mandibularis (D7473).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental consultation (D9310) provided on May 31, 2022. 
 
You asked the Plan to pay for the dental consultation. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within your 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a dental 
consultation (D9310) provided on May 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental filling provided by an out-of-network provider on 
March 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says 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 dental filling provided by an out-of-network provider on March 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composite dental services (D2393) provided on 
March 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for resin-
based composite dental services (D2393) provided on March 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental crown (D2740) provided on April 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 
 The Plan denied your request. The Plan says 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 dental crown (D2740) provided on April 13, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an abdominal x-ray provided to the enrollee on August 31, 
2021. 
 
You asked the Plan to pay for the x-ray. You say that this should be paid for. The Plan denied your request. The 
Plan says the enrollee was active on hospice at this time. 
 
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 an abdominal x-ray provided to the enrollee on August 31, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 16, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 70450 is bundled into payment for code 70496. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 16, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prolonged evaluation and management service provided 
on February 25, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the prolonged evaluation and management service. You say that the service was 
medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
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 did not pre-approve the 
prolonged evaluation and management service. We found no exception that would require the Plan to pay for 
the prolonged evaluation and management service. The records provided for review do not show that the 
service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the 
prolonged evaluation and management service provided on February 25, 2022, by an out-of-network (OON) 
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for compression stockings provided on 
January 3, 2022. 
 
You asked the Plan to waive the coinsurance for compression stockings. You say that you ordered these in 
2021 and they were delivered in 2022 so this should be charged using the 2021 benefits. The Plan denied your 
request. The Plan reprocessed the claim to remove the deductible and only apply $5-member responsibility.  
The Plan says the coinsurance applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay 10% 
coinsurance of the approved amount for DME.  
 
 
 
 You have been asked to pay $5 which is 10% of the allowed amount for compression stockings. The allowed 
amount is $49.98 (10% x $49.98= $5). Compression stockings fall within the Durable Medical Equipment 
(DME) and Related Supplies benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for 
compression stockings provided on January 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
criteria have not been met. 
 
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 does not indicate that the enrollee uses insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation (90791) provided on 
April 7, 2022. 
 
You asked the Plan to pay for the diagnostic service. You say that LPCs are exempt from Medicare and not 
allowed to bill. The Plan denied your request. The Plan says that the claim processed correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not eligible to enroll in the 
Medicare program. Therefore, we decided that the Plan does not have to pay for the psychiatric diagnostic 
evaluation (90791) provided on April 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous ablation. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the documentation shows lack of valve reflux and no documentation of pain severe 
enough to impair mobility, recurrent superficial phlebitis, recurrent ulcer, or bleeding. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the documentation does not meet coverage criteria and does not support the medical necessity of the 
procedure in question. The documentation does not satisfactorily demonstrate that despite all the patients 
ablations performed so far that she is having lifestyle limiting discomfort despite compression stocking use. As 
noted by the health plan, there is no documentation of reflux in the vein to be treated.  Therefore, coverage 
criteria have not been met and the determination cannot be overturned on the basis of medical necessity. 
 
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 endovenous ablation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical nutrition therapy; re-assessment and intervention 
(97803) provided from October 6, 2021, to December 30, 2021. 
 
You asked the Plan to pay for medical nutrition therapy services. You say that the enrollee is very engaged in 
their recovery. You say that The Plan denied your request. The Plan says the claims denied correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the 
Plan does not have to pay for the medical nutrition therapy; re-assessment and intervention (97803) provided 
from October 6, 2021, to December 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided by a chiropractor on April 6, 2022. 
 
You asked the Plan to pay for the office visit. You say that you do not understand why this service was not 
covered. The Plan denied your request. The Plan says chiropractic benefits are limited to manual manipulation 
of the spine to correct a subluxation and all other services are not covered. 
 
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 an office visit provided by a chiropractor on April 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement scooter. 
 
You asked the Plan to pre-approve a replacement scooter. You say that this new scooter is necessary for your 
condition. The Plan denied your request. The Plan says coverage for new durable medical equipment is 
provided every five years. 
 
The Plan must follow Medicare rules. Medicare rules say that in the absence of program instructions, Medicare 
Administrative Contractors may determine the reasonable useful lifetime of equipment, but in no case can it be 
less than 5 years. 
 
We looked at the file and Medicare rules. In this case, the record establishes you received a power operated 
vehicle within the last 5 years. The Plan has indicated that they will cover repairs for the equipment but not 
replacement as the reasonable useful lifetime of the power operated vehicle has not been exhausted. Based on 
this information, we decided that Medicare rules for coverage of a replacement scooter have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a replacement scooter.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting 
on April 3, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that the last time you did an overnight after 
a major procedure, you had a similar result. You say that you submitted an appeal and provided additional 
information that was requested. You also say that the claim was paid in the end. The Plan denied your request. 
The Plan says the drugs you received in the outpatient setting are considered self-administered. The Plan says 
self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drugs you received are 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 pay for the self-administered drugs 
provided in an outpatient setting on April 3, 2022.