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

 
We decided that the Plan does not have to pre-approve knee surgery services with the procedure codes 29880, 
29882 and 29883. 
 
You asked the Plan to pre-approve knee surgery services. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve knee surgery services. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the procedure codes at issue are not medically needed and not indicated for the 
enrollee's pathology based on magnetic resonance imaging in this case. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of knee surgery services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve knee surgery services with the procedure codes 29880, 29882 and 29883.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic casts (D0470) and two removable 
prosthodontic procedures (D5899 x2) provided on March 23, 2022, and March 29, 2022. 
 
You asked the Plan to pay for the diagnostic casts and removable prosthodontic procedures. You say that you 
were told you cannot get your bottom denture until you pay what they said you owe, but you already paid what 
you were supposed to. You also say that you do not have any more money to pay, and thought that is why you 
have insurance. The Plan denied your request. The Plan says these services are not covered expenses under 
your dental 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 pay for the 
diagnostic casts (D0470) and two removable prosthodontic procedures (D5899 x2) provided on March 23, 
2022, and March 29, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that you were approved for a left 
reverse total shoulder arthroplasty and will need inpatient admission after surgery. The Plan denied your 
request. The Plan says there is no documentation provided to support the expectation the enrollee will require a 
greater than 2 midnight stay. 
 
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 pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found you are approved for a left reverse total shoulder arthroplasty. The record 
does not document that the treating physician has a reasonable expectation of a length of stay spanning 2 or 
more midnights. 
 
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 pre-approve acute inpatient hospital care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction provided by an out-of-network provider on 
August 26, 2022. 
 
You asked the Plan to pay for the refraction. You say that you have to have your optic nerve checked regularly. 
You say you cannot afford this bill. The Plan denied your request. The Plan says the service is not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The service you asked the Plan to pay for are considered routine vision services or eyewear. Specifically, the 
refraction was not performed during a routine eye exam. Therefore, we decided that the Plan does not have to 
pay for the refraction provided by an out-of-network provider on August 26, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20610 billed for date of service July 12, 
2022. 
 
You asked the Plan to pay for procedure code 20610. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code 20610 is bundled into payment for code 20611.  
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 20610 
is a column II code to column I code 20611. 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 20610 billed for date of service July 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 20, 2022, billed with 
codes 81227, 81230, 81240, 81241, 81291, 81335 and 81355. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
January 20, 2022, billed with codes 81227, 81230, 81240, 81241, 81291, 81335 and 81355.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 81162, 81201, 81292, 81295, 81298, 81307, 
81317, 81405, and 81408 billed for date of service June 21, 2022. 
 
You asked the Plan to pay for the billed codes. You say that all services are separate and distinct services. The 
Plan denied your request. The Plan says payment for code 81162, 81201, 81292, 81295, 81298, 81307, 81317, 
81405, and 81408 is bundled into payment for code 81445. 
 
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 s81162, 81201, 81292, 81295, 81298, 81307, 81317, 81405, and 
81408 are column II codes to column I code 81445. 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 procedure codes 81162, 81201, 81292, 81295, 
81298, 81307, 81317, 81405, and 81408 billed for date of service June 21, 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 June 9, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you disagree with the denial. 
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 June 9, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99058 billed for date of service April 19, 
2020. 
 
You asked the Plan to pay for procedure code 99058. You say that you disagree with the denial. The Plan 
denied your request. The Plan says procedure code 99058 is considered bundled and not separately payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99058 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99058 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99058 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99058 billed for date of service April 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive oral evaluation - new or established patient
(D0150), prophylaxis - adult (D1110), and topical application of fluoride (D1208) provided on August 11,
2022.

You asked the Plan to pay for the dental services. You say that you wish to appeal as you are supposed to get
two cleanings per year and a fluoride treatment. The Plan denied your request. The Plan says your benefit for
the requested items or services $1,000 dollar limit was met.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's 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 items or services was exhausted on date of service July 27, 2022.
Therefore, we decided that the Plan does not have to pay for comprehensive oral evaluation - new or
established patient (D0150), prophylaxis - adult (D1110), and topical application of fluoride (D1208) provided
on August 11, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve normal saline solution infusion. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says that the services are not medically necessary. 
 
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 states that the saline solution infusion is not medically necessary; 
however, no medical records were received for review. Without medical records, a determination based on 
medical necessity cannot be supported. Therefore, we decided that the Plan has to pre-approve normal saline 
solution infusion.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc-One. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that Synvisc-One is covered when specific criteria are 
met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records do not indicate the enrollee 
had significant improvement in pain and functional capacity from the Synvisc-One injection on June 16, 2021. 
The physical therapy note dated January 3, 2023 states pain relief from the first injection lasted "about two 
weeks." The criteria for coverage are not met and the repeat Synvisc-One injection is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc-One.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to waive the copayment for ambulance transport provided on June 27, 2022. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that this should be covered. The 
Plan denied your request. The Plan says that 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 does not say in clear and accurate terms 
how much you should expect to pay for Ambulance services.  
 
We looked at your contract with the Plan. We did not see where the contract says enrollees must pay $100 
copayment for ambulance services. The Plan contract does not clearly say how much enrollees must pay for 
Ambulance services. This means that the Plan did not follow Medicare rules for disclosure of cost sharing 
information. Therefore, we decided that the Plan has to waive the copayment for ambulance transport provided 
on June 27, 2022.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the topical application of fluoride varnish, periodic oral 
evaluation, prophylaxis, complete series of x-rays and problem focused limited oral evaluation provided from 
June 29, 2022, to July 25, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denial. The Plan denied 
your request. The Plan says your benefit for the topical application of fluoride varnish has already been 
exhausted and the cost sharing was charged correctly.   
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 topical application of fluoride varnish was exhausted on date of service January 11, 
2022. Additionally, the cost sharing was charged correctly. Therefore, we decided that the Plan does not have 
to pay for the topical application of fluoride varnish, periodic oral evaluation, prophylaxis, complete series of 
x-rays and problem focused limited oral evaluation provided from June 29, 2022, to July 25, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is a medical necessity for you. The Plan 
denied your request. The Plan says rules for IRF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you are medically stable and do not need a physical medicine and rehabilitation 
physician's close supervision 3 times per week (at a minimum) for the ongoing management of any active or 
acute exacerbations of chronic medical conditions. While you would benefit from physical and occupational therapies, you do not need 3 hours a day for 5 days a week of therapies with multidisciplinary approach in an 
IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on August 21, 2022. 
 
You asked the Plan to pay for nursing facility care. You say that this was medically necessary. 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 nursing facility care 
provided on August 21, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a frenulectomy. 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denial. The Plan 
denied your request. The Plan says that this service is not a covered benefit under your dental 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. The Evidence of Coverage 
clearly says that a frenulectomy is covered once per lifetime. 
 
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 office visit provided on July 06, 2022. 
 
You asked the Plan to pay for office visit. 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 office visit provided on 
July 06, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oral appliance (21229). 
 
You asked the Plan to pre-approve the oral appliance. You say that the oral appliance is medically necessary. 
The Plan denied your request. The Plan says the requested service is not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Medicare does not cover oral appliances used to treat temporomandibular joint (TMJ) disorders that is causing 
the pain and issues with your jaw. 
 
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 an 
oral appliance (21229).