Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infrared therapy services (97026) provided from March 
7, 2021, to August 29, 2021. 
 
You asked the Plan to pay for the infrared therapy services. You say that you would like these services to be 
paid. The Plan denied your request. The Plan says infrared therapy is considered not reasonable and necessary 
by Medicare and is excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that the use of infrared and/or near-infrared light 
and/or heat, including monochromatic infrared energy, is non-covered for the treatment, including the 
symptoms such as pain arising from these conditions, of diabetic and/or non-diabetic peripheral sensory 
neuropathy, wounds and/or ulcers of the skin and/or subcutaneous tissues. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the infrared therapy services have not been met. Therefore, we decided that the Plan does not have 
to pay for the infrared therapy services (97026) provided from March 7, 2021, to August 29, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on February 9, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that transport 
to a medical facility was not required. The Plan denied your request. The Plan says you received treatment, but 
were not transported. The Plan also says that Medicare does not cover ambulance treatment with no transport. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on February 9, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on February 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical extraction (D7210) provided on April 7, 2022. 
 
You asked the Plan to pay for the dental service. You say that if you did not take care of the tooth that was a 
problem, it would be a greater risk to your health. You also say that this should be paid. The Plan denied your 
request. The Plan says extraction is not listed as a covered service. 
 
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 extraction is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the surgical extraction 
(D7210) provided on April 7, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy visit provided on February 23, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the psychotherapy visit. You say that you were told by a Plan representative that 
this provider was in-network. 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 
psychotherapy visit. We found no exception that would require the Plan to pay for the psychotherapy visit. The 
records provided for review do not show that the psychotherapy visit was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the psychotherapy visit provided on February 23, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eight additional chiropractic visits. 
 
You asked the Plan to pre-approve the additional chiropractic visits. You say that you walk much better when 
you receive the adjustments. The Plan denied your request. The Plan says eight additional chiropractic visits 
are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
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 pre-approve the additional chiropractic visits. Our 
reviewer says that the elements of the coverage criteria are not satisfied. Our physician reviewer found that the 
records provided indicate your improvement has plateaued and what you are receiving is called maintenance 
treatment, which is excluded from coverage by rule. 
 
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 additional chiropractic visits have not been met. Therefore, we decided that 
the Plan does not have to pre-approve eight additional chiropractic visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care (99223) provided on March 8, 2021. 
 
You asked the Plan to pay for the hospital care. You say that you did not receive proper notice of the enrollee's 
benefit determination. You say that this resulted in the untimely submission of this claim. You also say that the 
medically necessary services were rendered to the enrollee in good faith. The Plan denied your request. The 
Plan says the claim was not received in a timely manner. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the hospital care was not filed until March 16, 2022. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the initial hospital care (99223) provided on March 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient office visit (99204) and eye 
exam with photos (92250) provided on March 16, 2022. 
 
You asked the Plan to waive the copayment for the outpatient office visit and eye exam with photos. You say 
that you would like to appeal the copayment you were charged for the exam. The Plan denied your request. The 
Plan says you received a Medicare-covered vision exam to diagnose conditions of the eye. The Plan also says 
that the cost sharing applied to this exam was applied 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 $40 
copayment per visit for Medicare-covered Vision care.  
 
 
 
 You have been asked to pay a $40 copayment for the outpatient office visit and eye exam with photos. The 
outpatient office visit and eye exam with photos falls within the Medicare-covered Vision 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 the outpatient office visit (99204) and eye exam 
with photos (92250) provided on March 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on May 3, 2022. 
 
You asked the Plan to pay for the dental service. You say that you have temporomandibular joint (TMJ) 
dysfunction. You say this is a medical problem. You also say that this x-ray was needed to get a look at your 
jaw. The Plan denied your request. The Plan says the panoramic x-ray is not listed as a covered service. 
 
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 panoramic x-ray is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the panoramic x-
ray (D0330) provided on May 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the health club membership purchased on June 1, 2021. 
 
You asked the Plan to pay for the health club membership. You say that you received a letter saying you 
reached the maximum allowance, but you did not receive anything. The Plan denied your request. The Plan 
says a check was issued to you on April 15, 2022 for your 2021 Wellness Allowance Fitness reimbursement of 
$150. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
only up to $150 each calendar year. 
 
 
 
 The Plans rules for coverage of gym benefits have not been met because the record shows that a check was 
issued to you on April 15, 2022, reimbursing you $150 and exhausting your Wellness Allowance benefit. 
Therefore, we decided that the Plan does not have to pay for the health club membership purchased on June 1, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for alveoloplasty (D7310), removal of torus mandibularis 
(D7473), and extractions of tooth #3, 5, 6, 7 (D7210) provided on March 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that these procedures are necessary due to your 
cancer treatment. 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 alveoloplasty (D7310), removal of torus mandibularis (D7473), and extractions of tooth #3, 5, 6, 7 
(D7210) provided on March 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 6 extractions (D7210) provided on March 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that these procedures were necessary. You also say 
that they were the direct result of your head and neck radiation treatments. 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 extractions are not covered under this benefit when received from an out-of-network provider. Additionally, the services you are asking the Plan to pay for involve 
the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your 
teeth. These are dental services that are not covered or paid for by Medicare. The record shows that the 
extractions were performed after you received radiation treatments. Therefore, we decided that the Plan does 
not have to pay for the 6 extractions (D7210) provided on March 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine PCR panel testing (CPT code(s): 87799, 87482, 
87798, 87150) provided on March 18, 2022. 
 
You asked the Plan to pay for the urine PCR panel testing. You say that the claim should be paid. The Plan 
denied your request. The Plan says the PCR testing is considered unproven and 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 pay for the urine PCR panel testing. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found PCR testing is considered unproven and not medically necessary. The review has 
determined that the medical records provided did not meet the requirements listed in the NCD for Medicare 
coverage. 
 
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 urine PCR panel testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the urine PCR panel testing (CPT code(s): 87799, 87482, 87798, 87150) provided 
on March 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (95909, 95885, 95937) provided on November 
2, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are 
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. 
 
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 the services. Our reviewer says that the use of codes 95909, 
95885, and 95937 is not supported by the records provided. Our reviewer found that for CPT 95909, the 
procedure report describes stimulation of pedicle screws. Pedicle screw stimulation would not be reported with 
nerve conduction studies which measure amplitude and latency/velocity. Therefore, this procedure cannot be 
verified. For CPT 95885, per CPT code description "done with nerve conduction, amplitude and 
latency/velocity study".  The documentation does not support nerve conduction studies, therefore this procedure code cannot be verified. For CPT 95937.  The procedure report documents Train-of-Four 
Neuromuscular Junction (T04) testing was performed. Train-of-Four and Neuromuscular Junction testing are 
two different tests which would not be coded as one test. TO4 testing is inclusive to the intraoperative 
neuromonitoring procedure code, as no procedure code exists for TO4 testing. 
 
We looked at this coder'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 pay for the services (95909, 95885, 95937) provided on November 2, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care provided from February 23, 2022, 
to February 25, 2022. 
 
You asked the Plan to pay for the hospital care. The Plan denied your request. The Plan says original Medicare 
is responsible for payment. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on February 21, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for subsequent hospital 
care provided from February 23, 2022, to February 25, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services on January 21, 
2022. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you believed that you 
were inpatient and not outpatient as you signed an inpatient discharge notice. The Health Plan did receive a 
request for authorization for an inpatient stay however that the request was denied stating that the enrollee 
condition did not meet inpatient requirements. The Plan denied your request. The Plan says the cost sharing 
you are being charged 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 a $75 
copayment for each emergency room visit. If you are immediately admitted to the hospital, your cost-sharing 
amount for the emergency room visit will be waived. Emergency care refers to services that are: furnished by a 
provider qualified to furnish emergency services and needed to evaluate or stabilize an emergency medical 
condition. 
 You have been asked to pay a $75 copayment for emergency room services. Emergency room services fall 
within the Emergency 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 emergency 
room services on January 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute 
setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee 
was admitted with lower extremity cellulitis and ulcers in the setting of peripheral vascular disease and acute 
kidney injury. The record indicates that the enrollee is improving but still requires acute care services before 
transitioning to a lower level of care. The enrollee continues to receive acute care services, and these have not 
been denied. The medical record does not indicate that the enrollee requires services that he is not currently 
receiving but that would be available at the LTACH facility. Our physician reviewer found that the enrollee's 
condition does not meet Medicare criteria for LTACH services.  
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service March 16, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says procedure code 99100 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service March 16, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea. 
 
You asked the Plan to pre-approve Eylea. You say that the enrollee has been treated with Avastin and Eylea, 
and the doctor wishes to proceed with Eylea. The Plan denied your request. The Plan says the records received 
did not say that the enrollee did not respond well to a trial of Avastin (Bevacizumab), the enrollee had an 
adverse event from the Avastin (Bevacizumab) injection, or there is any reason the enrollee cannot use Avastin. 
 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 Eylea. Our reviewer says that the 
elements of the coverage criteria are not satisfied, and the requested service cannot be recommended. Our 
physician reviewer found the records provided support the fact that the requested medication is a new start, and 
do not indicate that the enrollee is already being treated with the requested medication for the noted condition. 
The provided records do not indicate that the enrollee has tried and failed the Plan's preferred step one 
alternative. Our reviewer also found that the record does not indicate that the enrollee has a contraindication to, 
or would have an adverse effect from the Plan's preferred step one alternative. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea.