Persius/hicric huggingface dataset:
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 October 13, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. 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 October 
13, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital care provided from August 2, 2022, to August 7, 
2022. 
 
You asked the Plan to pay for the inpatient care. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis, and 
pre-approved care.   
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the inpatient care. Our reviewer says that the 
records indicate that the care provided was medically necessary. Our physician reviewer found the enrollee 
presented to the ED with shortness of breath and weight gain. It would not have been medically reasonable to 
delay the services until when enrollee returned to the service area. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the inpatient care have been met. Therefore, we decided that the Plan has to pay 
for inpatient hospital care provided from August 2, 2022, to August 7, 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: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that Prolia is medically necessary. The Plan denied your 
request. The Plan says that a trial of an oral bisphosponate and zoledronic acid is required before alternatives 
can be considered. 
 
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 Prolia. Our reviewer says that Prolia is 
medically necessary. Our physician reviewer found the clinical documentation in the case file suggests that an 
oral bisphosponate and zoledronic acid would likely be less effective and would likely have adverse effects for 
the enrollee 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 Prolia have been met. Therefore, we decided that the Plan has to pre-approve 
Prolia.  
 
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 procedure code 99305 billed for March 15, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 99305 is not supported. 
 
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 99305 is initial nursing facility care, per day, for the 
evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) 
requiring admission are of moderate severity. Typically, 35 minutes are spent at the bedside and on the patient's 
facility floor or unit. 
 
We asked our coder 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 these services. Our reviewer says that procedure code 99305 is not supported. Our reviewer found the submitted records do not contain documentation of a detailed 
comprehensive history. There is no documentation of a comprehensive exam and medical decision making of 
moderate complexity. 
 
We looked at this coder'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 pay for procedure code 99305 billed for March 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Special Supplemental Benefits for the Chronically Ill 
(SSBCI) coverage. 
 
You asked the Plan to pre-approve SSBCI coverage. You say that SSBCI coverage is medically necessary and 
supported by the records provided. The Plan denied your request. The Plan says there is no documentation that 
the enrollee meets the criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
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 SSBCI coverage. Our reviewer says that the 
criteria for SSBCI coverage have not been met. Our physician reviewer found that the documentation does not 
show recent admissions to the hospital or emergency department visits, clinical status describing high risk for 
hospitalization, or medically complex conditions that are life threatening or significantly limiting overall 
health.  
 We looked at this physicians review, the file and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SSBCI coverage have not been met. Specifically, we have confirmed that you 
do not have one of the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the 
Plan does not have to pre-approve Special Supplemental Benefits for the Chronically Ill (SSBCI) coverage.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve routine transportation exceeding 60 miles. 
 
You asked the Plan to pre-approve routine transportation. You say that you have a follow-up appointment after 
surgery, so you need this transportation request approved. The Plan denied your request. The Plan says the 
requested trip exceeding the mileage limitation of 60 miles, is excluded from coverage. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when each one-way trip does not exceed 60 miles based on the 
most efficient route.   
We looked at your request, the records in the case file, and the rules. With the information provided, the 
requested destination is beyond the 60-mile one-way limit. Based on this information, we decided that the 
Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does 
not have to pre-approve routine transportation exceeding 60 miles.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
September 13, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service September 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
October 26, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service October 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatments (97810, 97811) provided on 
November 4, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services are not payable as they were 
rendered by an ineligible provider. 
 
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. 
 
A review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the acupuncture treatments (97810, 
97811) provided on November 4, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Leqvio. 
 
You asked the Plan to pre-approve Leqvio. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says step-therapy rules for coverage of the requested drug 
have not been met. 
 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 Leqvio. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires a trial of atorvastatin before they will approve the requested drug, Leqvio. There is no indication 
in the case record that the enrollee has tried and failed the required drug. Based on the medical records 
provided and the Medicare-approved major drug compendia, there is no indication that the Plan's required drug 
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 Leqvio have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Leqvio.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the comprehensive oral evaluation (D0150), intraoral-
complete series of radiographic images (D0210), and the scaling in the presence of generalized moderate or 
severe gingival inflammation (D4346) provided on November 3, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the comprehensive oral 
evaluation has already been exhausted. Dental scaling in the presence of generalized moderate or severe 
gingival inflammation is not a covered benefit. Additionally, you are responsible for the charged amount above 
the Plans cost-sharing amount for the intraoral-complete series of radiographic images as they were rendered 
by 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. 
 
The record shows your benefit for the comprehensive oral exam was exhausted on date of service June 24, 
2021. Specifically, the Plan contract provides coverage for one comprehensive oral exam every three years. 
You previously received a comprehensive oral exam on June 24, 2021, less than three years prior, which was 
paid for by the Plan. Therefore, you have exhausted the allowable benefit for this service. Additionally, you 
disputed the payment issued by the Plan for the intraoral-complete series of radiographic images provided. You 
have been asked to pay the difference between the out-of-network providers charges and the Plans payment.  
The Plan paid the maximum allowed charge for this service. Also, dental scaling in the presence of gingival 
inflammation is not a covered benefit. Therefore, we decided that the Plan does not have to pay more for the 
comprehensive oral evaluation (D0150), intraoral-complete series of radiographic images (D0210), and the 
scaling in the presence of generalized moderate or severe gingival inflammation (D4346) provided on 
November 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - complete series of radiographic images (D0210) 
provided on October 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that you tried to obtain a copy of your x-rays on 
October 20, 2022. You also say that the provider would not provide them due to the length of time they were 
taken on April 18, 2022. 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 April 18, 2022. 
Therefore, we decided that the Plan does not have to pay for intraoral - complete series of radiographic images 
(D0210) provided on October 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a re-evaluation - limited, problem focused (D0170) provided 
on November 16, 2022. 
 
You asked the Plan to pay for the re-evaluation - limited, problem focused (D0170). You say that you were not 
aware the service was not a covered benefit. 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 re-
evaluation - limited, problem focused (D0170) provided on November 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the upper partial denture (D5213) and the lower partial 
denture (D5214) provided on September 20, 2022. 
 
You asked the Plan to pay for the dental items. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the enrollees annual dental maximum benefit 
has 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 that the enrollees benefit for the services provided was exhausted on date of service August 26, 2022. 
Specifically, the Plan contract states that the annual dental maximum benefit is $4,000. The Plan issued 
payments previously for dental services provided to the enrollee in the amount of $4,000 for the 2022 calendar 
year.  Therefore, the enrollee has exhausted the allowable annual dental benefit. Therefore, we decided that the Plan 
does not have to pay for the upper partial denture (D5213) and the lower partial denture (D5214) provided on  
September 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on December 15, 2021. 
 
You asked the Plan to pay for dental services. You say that the medical treatments you received were needed 
for periodontal disease and health. The Plan denied your request. The Plan says the denial of payment for these 
services is correct, because this provider has opted out of Medicare and is not eligible for payment. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for dental 
services provided on December 15, 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 October 11, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. 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 October 11, 
2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the acupuncture treatments (97810, 97811) provided from December 7, 
2022, through December 28, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that these services are not payable because 
you have exhausted the allowable benefit. 
 
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. Specifically, the Plan has stated that you have exhausted the allowable 
supplemental acupuncture benefit; therefore, the services provided and billed with a diagnosis of hip pain are 
not payable. However, the Plan has not provided substantive evidence to demonstrate that you previously 
received these services or that the services were paid for by the Plan. The Plan has not substantiated their 
denial; therefore, we must find in your favor. Therefore, we decided that the Plan has to pay for the 
acupuncture treatments (97810, 97811) provided from December 7, 2022, through December 28, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
November 4, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service November 4, 2022.