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

 We decided that the Plan does not have to pay for procedure code 76705 billed for date of service August 8, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 76705 is bundled into payment for code 93976. 
 
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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service August 8, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve terminal device, multiple articulating digit, includes motor(s), 
initial issue or replacement (CPT code L6715). 
 
You asked the Plan to pre-approve the item. You say that the item is necessary. The Plan denied your request. 
The Plan says that the requested prosthesis is not reasonable and necessary per Medicare criteria, as it exceeds 
the enrollee's need. 
 
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 the item. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found per physician note the medical necessity criteria met for body powered fingers following an 
amputation. 
 
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 item have been met. Therefore, we decided that the Plan has to pre-approve 
terminal device, multiple articulating digit, includes motor(s), initial issue or replacement (CPT code L6715).  
 
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transcatheter aortic valve replacement (TAVR)
procedure.
You asked the Plan to pre-approve TAVR procedure. You say that the services are necessary. The Plan denied
your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that the Centers for Medicare & Medicaid Services
(CMS) covers transcatheter aortic valve replacement (TAVR) under Coverage with Evidence Development
(CED) with certain conditions.
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 TAVR procedure. Our reviewer says
that the services are not medically necessary. Our physician reviewer found recent echocardiography did show
evidence of significant aortic stenosis or regurgitation. Guidelines would not support aortic valve replacement
based on the submitted medical records. As a result, at this time the requested TAVR would not be considered
medically necessary in this enrollee's clinical management based on the submitted documentation.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of TAVR procedure have not been met. Therefore, we decided that the Plan does
not have to pre-approve a transcatheter aortic valve replacement (TAVR) procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the collection and application of autologous blood 
concentrate product (D7921) and the sinus augmentation with bone or bone substitutes (D7951). 
 
You asked the Plan to pre-approve the collection and application of autologous blood concentrate product 
(D7921) and the sinus augmentation with bone or bone substitutes (D7951). You say that the services are 
medically necessary. The Plan denied your request. The Plan says the services are not covered 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage the collection and application of 
autologous blood concentrate product (D7921) and the sinus augmentation with bone or bone substitutes 
(D7951) are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pre-approve the collection and application of autologous blood concentrate product (D7921) and the sinus 
augmentation with bone or bone substitutes (D7951).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair accessory, electronic connection 
between wheelchair controller and one power seating system motor, including all related electronics, indicator 
feature, mechanical function selection switch, and fixed mounting hardware (CPT code E2310). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the enrollee can control the power tilt through its own switch, there is no need to control 
this power option through the joystick. 
 
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 DME. Our physician reviewer 
found the enrollee has sufficient strength to manage standard switches on a power wheelchair. 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 DME have not been met. Therefore, we decided that the Plan does not have to pre-approve 
power wheelchair accessory, electronic connection between wheelchair controller and one power seating 
system motor, including all related electronics, indicator feature, mechanical function selection switch, and 
fixed mounting hardware (CPT code E2310).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve resin-based composite (D2330 x1), endosteal implant 
(D6010 x2), custom fabricated abutment (D6057 x2), bone graft at time of implant placement (D6104 x2), 
abutment supported porcelain/ceramic crown (D6058 x2), retainer onlay - porcelain/ceramic (D6609 x2), 
localized delivery of antimicrobial agents (D4381 x1), topical application of fluoride varnish (D1206 x1), and 
scaling in presence of generalized moderate or severe gingival inflammation (D4346 x1). 
 
You asked the Plan to pre-approve the dental services. You say that you need the implants. The Plan denied 
your request. The Plan says the denial is correct, because these services are not covered by the Plans dental 
benefits or they are covered but the coverage 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 endosteal implant (D6010 x2), custom fabricated abutment (D6057 x2), bone graft at time of implant 
placement (D6104 x2), abutment supported porcelain/ceramic crown (D6058 x2) are denied because the limit 
on these services is 2 per year and 2 units of each of these services have been approved.  
 
The resin-based composite (D2330) is denied because the limit is 4 per year and 4 were approved on the 
original request. 
 
The retainer onlay - porcelain/ceramic (D6609), and localized delivery of antimicrobial agents (D4381) are not 
covered by the Plans dental benefits. 
 
The topical application of fluoride varnish (D1206), and scaling in presence of generalized moderate or severe 
gingival inflammation (D4346) are both covered only for ages 0-20 and the enrollee is older than 20. 
 
The plan agreed to pre-approve the pontic - porcelain fused (D6240 x2), removal of impacted tooth (D2740 
x2), endosteal implant (D6010 x2), custom fabricated abutment (D6057 x2), porcelain/ceramic crown (D6058 
x2), and (D6104 x2).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a comprehensive hearing test and a 
specialist office visit provided on June 6, 2022, to July 13, 2022. 
 
You asked the Plan to waive the copayment for a comprehensive hearing test and a specialist office visit. You 
say that you think the copayments is too high. 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 $35 
copayment for hearing services and a $40 copayment physician/practitioner services/specialist.  
 
You have been asked to pay a $35 copayment for a comprehensive hearing test and a $40 copayment for a 
specialist office visit. The total amount you are being asked to pay is $75 ($35 + $40 = $75). 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 a comprehensive hearing test and a specialist office visit provided on 
June 6, 2022, to July 13, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on May 5, 2022. 
 
You asked the Plan to pay for ambulance services. You say that the enrollee was having difficulty breathing 
and paramedics were called but vitals were normal, so they were not transported to the urgent care. You say 
that you are requesting the Plan reimburse the billed amount of $453 for the ambulance. The Plan denied your 
request. The Plan says the service in question is not covered under the Member's contract under any normal 
circumstances. 
 
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 May 5, 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 ambulance services provided on May 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2752) and the core buildup (D2950) for tooth #16 
provided on August 11, 2022, and August 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told crowns would be covered at 50% 
and you would like the Plan to pay for the dental services. The Plan denied your request. The Plan says the 
denial of authorization for these services is correct, because crowns and core buildup are not covered by the 
Plan. Also, the Plan verified the enrollee was told restorations were covered at 50% and there was no mention 
of crowns. 
 
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 crown 
(D2752) and the core buildup (D2950) for tooth #16 provided on August 11, 2022, and August 15, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance on August 12, 2022. 
 
You asked the Plan to waive the copayment for ambulance. You say that you want to appeal the amount being 
charged. 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 $290 
copayment per date of service regardless of the number of trips for ambulance services. Covered ambulance 
services include fixed wing, rotary wing, and ground ambulance services, to the nearest appropriate facility that 
can provide care only if they are furnished to a member whose medical condition is such that other means of 
transportation could endanger the person's health or if authorized by the plan. 
 
 
 
 
 You have been asked to pay a $290 copayment for ambulance. This item/service falls within the Ambulance 
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 ambulance on August 12, 
2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient hospital clinic visit provided 
on July 6, 2022. 
 
You asked the Plan to waive the copayment for an outpatient hospital clinic visit. You say that you would like 
to appeal the $115.98 copayment for the visit because you already paid a $50 copayment prior to the visit and 
then received another bill. 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 $300 
copayment for Medicare-covered outpatient hospital services.  
 
You have been asked to pay a copayment of $115.98 for an outpatient hospital clinic visit, which is less than 
the standard $300 copayment. This item/service falls within the Outpatient Hospital 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 outpatient hospital clinic visit provided on July 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on August 31, 2022. 
 
You asked the Plan to pay for a nursing facility visit. You say that The enrollee is in a facility and the facility 
should have obtained the prior 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).there was no preauthorization by a primary care provider (this is different than a 
referral) for an out-of-network (OON) provider or facility, and this was not an emergency. Therefore, the 
decision is upheld. Therefore, we decided that the Plan does not have to pay for a nursing facility visit provided 
on August 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care services provided on February 23, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for wound care services. You say that the attached records support these services. 
The Plan denied your request. The Plan says there is no authorization on file for these services. 
 
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 wound care services provided on February 23, 
2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the out-of-network continuous positive 
airway pressure (CPAP) supplies provided on September 30, 2021. 
 
You asked the Plan to waive the deductible for the out-of-network continuous positive airway pressure (CPAP) 
supplies. You say that there should not be a deductible since the provider is in network. 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 $1,500 
deductible for out-of-network durable medical equipment (DME) and related supplies. 
 
You have been asked to pay a $1,500 deductible for the out-of-network continuous positive airway pressure 
(CPAP) supplies. This item/service falls within the out-of-network durable medical equipment (DME) and 
related 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.The file shows that the Plan verified the provider is not a network provider. Therefore, we decided that the 
Plan does not have to waive the deductible for the out-of-network continuous positive airway pressure (CPAP) 
supplies provided on September 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging provided on April 25, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for imaging. You say that you are requesting reconsideration. The Plan denied your 
request. The Plan says if the enrollee needs Medicare-covered medical care and a network provider is unable to 
provide this care, the enrollee may be able to get care from an out-of-network provider. Our plan must confirm 
there is not a network provider available and contact the plan to request authorization for the enrollee to obtain 
services from an out-of-network provider. If approved, the out-of-network provider will be issued an 
authorization to provide the service(s). 
 
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 imaging provided on April 25, 2022, by an out-of-
network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mental health services provided on December 28, 2021. 
 
You asked the Plan to pay for mental health services. You say that patient was self referred and not through a 
pcp. 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).there was no preauthorization by a primary care provider (this is different than a referral) for an out-of-network (OON) provider or facility, and this was not an emergency. Therefore, the 
decision is upheld. Therefore, we decided that the Plan does not have to pay for mental health services 
provided on December 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathology and laboratory services provided on July 20, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for pathology and laboratory services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says there is no prior authorization on file. Services can be 
obtained from an in-network provider. 
 
 
 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 pathology and laboratory services provided on 
July 20, 2022, by an out-of-network (OON) provider.