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

 
We decided that the Plan does not have to pre-approve Icosapent Ethyl. 
 
You asked the Plan to pre-approve Icosapent Ethyl. You say that Icosapent Ethyl is medically necessary. The 
Plan denied your request. The Plan says this drug is not eligible for coverage under the Part B medical benefit. 
 
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 pre-approve Icosapent Ethyl.  
 
Benefits for Icosapent Ethyl may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatments (97810) provided from June 2, 
2022, through June 19, 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 provided do not meet criteria for 
coverage. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
 We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the acupuncture services in this case were not 
rendered under the supervision of a physician, physicians assistant, nurse practitioner, or clinical nurse 
specialist. Therefore, we decided that the Plan does not have to pay for the acupuncture treatments (97810) 
provided from June 2, 2022, through June 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ophthalmic diagnostic imaging 
provided on September 20, 2022. 
 
You asked the Plan to waive the copayment for the ophthalmic diagnostic imaging. You say that you were told 
you would not be charged for this service. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $25 
copayment for physician services to diagnose and treat diseases and conditions of the eye. 
 
You have been asked to pay a $25 copayment for the ophthalmic diagnostic imaging. This item/service falls 
within the 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 
ophthalmic diagnostic imaging provided on September 20, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the toenail excision provided on June 11, 2022. 
 
You asked the Plan to pay for the excision. You say that you are appealing with supporting records. 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. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the toenail excision provided on June 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatments (97810) provided from July 25, 
2022, through August 23, 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 provided do not meet criteria for 
coverage. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
 We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the acupuncture services in this case were not 
rendered under the supervision of a physician, physicians assistant, nurse practitioner, or clinical nurse 
specialist. Therefore, we decided that the Plan does not have to pay for the acupuncture treatments (97810) 
provided from July 25, 2022, through August 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on September 14, 2022. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration. 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 lab testing provided on 
September 14, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Botox (J0585). 
 
You asked the Plan to pre-approve Botox. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says the requested drug is prescribed for an off-label, not 
medically accepted use. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Botox. Our reviewer says that the 
request is not medically reasonable and necessary in this case. Our physician reviewer found that the Medicare-
approved major drug compendia do not support Botox injections, 100 units every 90 days, for treatment of 
achalasia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Botox (J0585).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64447 billed for date of service February 17, 
2022. 
 
You asked the Plan to pay for procedure code 64447. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 64447 is bundled into payment for code 01402.  
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 64447 
is a column II code to column I code 01402. 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 64447 billed for date of service February 17, 
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 
July 30, 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 July 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of impacted tooth - completely bony (D7240) 
Tooth 1, 16, 17 and 32. 
 
You asked the Plan to pre-approve dental services. You say that you were told you need the requested services, 
and you would like the Plan to pay for them. The Plan denied your request. The Plan says this service is not 
covered under your 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. Removal of impacted tooth - 
completely bony (D7240) is not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D7240 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve removal of 
impacted tooth - completely bony (D7240) Tooth 1, 16, 17 and 32.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the primary care visit for device irrigation 
provided on June 29, 2022. 
 
You asked the Plan to waive the copayment for the primary care visit for device irrigation. You say that these 
copayments are excessive. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $15 
copayment for each Medicare-covered primary care doctor visit (including telehealth services and urgently 
needed services) furnished in a physicians office, certified ambulatory surgical center, hospital outpatient 
department or any other location.   
 
 
 You have been asked to pay a $15 copayment for the primary care visit for device irrigation. This item/service 
falls within the physician/practitioner services, including doctors office visits 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 primary care visit for device irrigation provided on June 29, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 96374 billed for date of service June 3, 2022. 
 
You asked the Plan to pay for procedure code 96374. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 96374 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 96374 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 96374 billed for date of service June 3, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, emergency 
transport and ground mileage provided on August 20, 2022. 
 
You asked the Plan to pay for the ambulance service, basic life support, emergency transport and ground 
mileage. You say that this claim was denied as out-of-network but claims submitted under the same provider 
have been paid recently. The Plan denied your request. The Plan says the ambulance transport was not 
medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 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 ambulance service, basic life support, 
emergency transport and ground mileage. Our reviewer says that the transportation via ambulance to the 
emergency department was not medically necessary. Our physician reviewer found the enrollee did not require 
the expertise of trained personnel or the equipment available only on an ambulance in order to effectuate a safe 
transport. Transportation could have been provided by other means (stretcher van, wheelchair van, private care, 
taxi) without endangering the enrollee's condition. 
 
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 ambulance service, basic life support, emergency transport and ground 
mileage have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance service, 
basic life support, emergency transport and ground mileage provided on August 20, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the acupuncture treatments (97810, 97811) provided from September 9, 
2021, through October 14, 2021. 
 
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 the services were denied due to a non-
applicable diagnosis billed. Additionally, the claims are not payable as they were submitted untimely. 
 
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 contract provides a wellness allowance benefit for 
acupuncture services rendered by a licensed acupuncturist. The case file provided does not demonstrate that 
this benefit has been exhausted. Additionally, the Plan has not clearly demonstrated that the claims were 
submitted untimely. 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 
September 9, 2021, through October 14, 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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation provided on June 15, 
2022. 
 
You asked the Plan to pay for the psychiatric diagnostic evaluation. You say that the physician provided 
medically necessary services and the claim should be paid at the maximum amount allowed. 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. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the psychiatric diagnostic evaluation provided on June 15, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (procedure code G0483) provided to the 
enrollee on June 23, 2022. 
 
You asked the Plan to pay for the services. You say that the billed charges are appropriate for the level of 
acuity and intensity of the medical services provided and for the expertise required to provide the services 
rendered. The Plan denied your request. The Plan says the provider did not submit progress notes that are 
needed in order to determine the clinical utility of this testing. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the services have been met. Our 
physician reviewer found that the only records provided are the test results of a urine drug test and the 
diagnosis codes cited above. Provided records do not document any detailed medical history, physical examination, assessment, or treatment plan justifying the testing ordered. Therefore, we decided that the Plan 
does not have to pay for drug testing services (procedure code G0483) provided to the enrollee on June 23, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve abutment supported porcelain fused to metal crown 
(high noble metal) (D6059) Tooth #12 and 14. 
 
You asked the Plan to pre-approve dental services. You say that due to having pain and difficulty eating, you 
need to have the requested services approved. The Plan denied your request. The Plan says this service is not 
covered under your Plan. 
 
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. Abutment supported porcelain 
fused to metal crown (high noble metal) (D6059) is not covered under the Plan's dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D6059 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve abutment 
supported porcelain fused to metal crown (high noble metal) (D6059) Tooth #12 and 14.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of impacted tooth - completely bony (D7240 
x4). 
 
You asked the Plan to pre-approve the removal of the impacted tooth - completely bony (D7240 x4). You say 
that this procedure needs to be completed under intravenous sedation due to severe apprehension and the 
complexity of the extractions. 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 Plan's 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 
removal of impacted tooth - completely bony (D7240 x4).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient surgery provided on July 25, 2022. 
 
You asked the Plan to pay for an inpatient surgery. You say that we depend on the facility staff to verify 
eligibility and to obtain authorization. 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 an inpatient surgery 
provided on July 25, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care, per day (99223) rendered by the out-
of-network (OON) provider on April 20, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out-of-network 
provider, without prior authorization. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the initial hospital care, per day (99223) rendered by the out-of-network (OON) 
provider on April 20, 2022.