Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prosthetic gasket. 
 
You asked the Plan to pre-approve the requested service. The Plan denied your request. The Plan says the 
request is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that lower limb prostheses are only covered under 
certain medical indications.  
 
 We looked at the file and Medicare rules. We find that the requested gasket (L7700) is not covered for use with 
the approved suspension locking mechanism (codes L5671 and L5673). Based on this information, we decided 
that Medicare rules for coverage of the requested service have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a prosthetic gasket.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 10, 2022, by an OON 
provider. 
 
You asked the Plan to pay for an office visit. You say that you are requesting a reconsideration for payment. 
The Plan denied your request. The Plan says the out-of-network services were not authorized. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for an office visit provided on January 10, 2022, by an 
OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic analysis for the HRAS gene. 
 
You asked the Plan to pre-approve the analysis of the HRAS gene (requested under code 81403). You say that 
testing of the requested genes is medically required for this enrollee's condition. The Plan denied your request. 
The Plan says the requested testing has been approved on appeal, except for testing of the HRAS gene as 
Medicare does not cover this as testing is not likely to impact treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that testing of certain genes, such as HRAS, is 
noncovered due to the low likelihood of an impact on treatment.  
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the analysis of the HRAS gene have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genetic analysis for the HRAS gene.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection provided on May 4, 2022. 
 
You asked the Plan to waive the coinsurance for an injection. You say that you were not made aware of this 
charge and therefore you should not need to pay it. The Plan denied your request. The Plan says the 
coinsurance charged was 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 20% 
coinsurance for Medicare Part B prescription drugs. The allowed amount of this item is $1828.40 resulting in a 
coinsurance amount of $365.68 ($1828.40 x 20% = $365.68). 
 
You have been asked to pay a $365.68 coinsurance for an injection. An injection falls within the Medicare Part 
B Prescription Drugs benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for an 
injection provided on May 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of implant (D6100) for teeth # 7 and 24. 
 
You asked the Plan to pre-approve the dental services. You say that part of your implant was removed. You say 
that the other piece needs to be removed. You say that The Plan denied your request. The Plan says removal of 
implant 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 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 implant (D6100) for teeth # 7 and 24.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve VENTRIS Contour BA Allograft for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the clinical value and effectiveness of the VENTRIS Contour BA 
Allograft in the setting of a lumbar spine fusion surgery has not been demonstrated in the peer-reviewed 
literature. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. There is limited 
published, large-scale, long-term peer-reviewed literature that shows this request to be an effective and/or safe 
treatment for the enrollee's pathology. Further studies are needed. Our physician reviewer found that the 
enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve VENTRIS Contour BA Allograft for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve closed ostomy pouches (A4423 x1080) and drainable 
ostomy pouches (A4427 x240). 
 
You asked the Plan to pre-approve the ostomy supplies. You say that due to medical reasons, the enrollee needs 
more supplies than usual. The Plan denied your request. The Plan says based on Medicare guidelines and the 
records provided the additional request for A4423 x1080 and A4427 x240 is excessive and is more than what is 
reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ostomy supplies have not been met. Therefore, we decided that the Plan does not have to pre-
approve closed ostomy pouches (A4423 x1080) and drainable ostomy pouches (A4427 x240).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for X-rays of the neck provided on December 
22, 2021. 
 
You asked the Plan to waive the copayment for the X-rays. You say that you did not have X-rays done on that 
day. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
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 for each standard X-ray or ultrasound.  
 
The records show that the X-ray imaging was performed on December 22, 2021. Therefore, you have been 
asked to pay 38.53, which is less than the $40 copayment for the X-rays. The X-rays fall within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for X-rays of the neck provided on December 22, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 physical therapy visits. 
 
You asked the Plan to pre-approve therapy visits. You say that additional physical therapy is medically 
necessary. The Plan denied your request. The Plan says these services are not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy visits. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that there is no documentation regarding a re-assessment of the 
enrollees motor strength as well as improvement in function. Therefore, the requested physical therapy cannot 
be considered medically necessary since the guideline criteria has not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of therapy visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 10 physical therapy visits.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve endovascular repair of an abdominal aortic aneurysm (34705) for 
the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that that the documentation does not support that the aneurysm is of 
sufficient size or is demonstrating worrisome increase in size to warrant repair at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 requested services are considered medically reasonable and necessary in this case. The health plan denial is 
based on standard size criteria for the abdominal aortic aneurysm. However, this is not the main indication for 
the surgery. In this case, the 3.3 cm iliac artery aneurysm represents the indication for treatment that will 
simultaneously treat the abdominal aortic aneurysm (AAA). This procedure has been delayed for some time 
waiting for the patients venous ulcer to heal. There is now a window for treatment. 3.3 cm is a reasonable size 
for treatment of an iliac artery aneurysm. Our physician reviewer found that the enrollee's condition meets 
criteria for coverage of these 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 these services have been met. Therefore, we decided that the Plan has to pre-
approve endovascular repair of an abdominal aortic aneurysm (34705) for the enrollee.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 3, 
2021. 
 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 December 3, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat pouch, small side guards, and anodize color 
orange for a manual wheelchair. 
 
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 covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The items at issue in this appeal do not serve a purpose that is primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve a seat pouch, small side guards, and anodize color orange for a manual wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the addition to lower limb prosthesis, vertical shock 
reducing pylon feature (L5988). 
 
You asked the Plan to pre-approve the vertical shock reducing pylon feature. You say that your basis of this 
appeal is that the enrollee meets CMS requirements for the proposed VASS system L5781 and L5988 and 
ultra-light materials, L5940. The Plan denied your request. The Plan says the records do not support that L5988 
is medically reasonable and 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 the vertical shock reducing pylon 
feature. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the requested items/services are not considered medically 
reasonable and necessary 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 the vertical shock reducing pylon feature have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the addition to lower limb prosthesis, vertical shock 
reducing pylon feature (L5988).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 24, 
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 March 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wigs purchased on December 2, 2021. 
 
You asked the Plan to pay for wigs, any type. You say that this wig purchase was medically necessary. The 
Plan denied your request. The Plan says wigs are not a covered benefit, and you did not purchase these items 
from an eligible Medicare durable medical equipment provider. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. In this case, although the wig may be appropriate, it 
does not meet the definition of the above benefit categories. It is not considered DME because it does not 
directly treat a medical condition. It does not meet the Medicare definition of a prosthetic because it does not 
replace an internal body organ or attached tissue. As such, it is noncovered by Medicare. Furthermore, the Plan 
does not offer a supplemental benefit which would provide coverage for a wig. Therefore, we decided that the 
Plan does not have to pay for wigs purchased on December 2, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the comprehensive oral evaluation (D0150) provided on April 12, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that you do not feel the provider 
rendered this service. The Plan denied your request. The Plan says that your benefit for the requested item or 
service has already been exhausted. 
 
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.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your benefit for the requested item or service was previously 
exhausted. Therefore, we decided that the Plan has to pay for the comprehensive oral evaluation (D0150) 
provided on April 12, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 
24, 2021. 
 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 November 24, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an out-of-network chiropractic visit 
provided on June 22, 2021. 
 
You asked the Plan to waive the copayment for an out-of-network chiropractic visit. You say that if you had 
known that the provider was out-of-network, you would not have started treatment. The Plan denied your 
request. The Plan says the copayment applied was 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 $55 
copayment for chiropractic services.  
 
You have been asked to pay the allowed amount of $40 which is less than the $55 copayment for an out-of-
network chiropractic visit. An out-of-network chiropractic visit falls within the Chiropractic Services 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 an out-of-network chiropractic visit provided 
on June 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain/ceramic crown (D2740) and a core buildup, 
including any pins when required (D2950). 
 
You asked the Plan to pre-approve these dental items. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says you have not provided documentation that 
sufficiently demonstrates the medical necessity of the requested dental items. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 requested items have been met.  
Therefore, we decided that the Plan does not have to pre-approve a porcelain/ceramic crown (D2740) and a 
core buildup, including any pins when required (D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for four intraoral images (D0230) provided by a participating 
provider on April 5, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. 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 5, 2022. Therefore, 
we decided that the Plan does not have to pay for four intraoral images (D0230) provided by a participating 
provider on April 5, 2022.