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

 
We decided that the Plan does not have to pay for the CT scan of the abdomen and pelvis provided on 
September 8, 2022. 
 
You asked the Plan to pay for the CT scan. You say that you are appealing the denial. 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 CT scan of the abdomen and pelvis provided on 
September 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 25, 2022. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services provided. 
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 office visit provided 
on August 25, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible and copayment for a transthoracic 
echocardiogram (TTE) with doppler provided on August 5, 2022. 
 
You asked the Plan to waive the deductible and copayment for the TTE with doppler. You say that you do not 
understand why the deductible was applied in this case. 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. Your 
contract with the Plan says that there is a $500 deductible which applies to certain items and services.  
 
The item or service you asked the Plan to waive the deductible and copayment for falls within the radiological 
diagnostic tests, not including x-rays benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $500 deductible which applies to radiological diagnostic tests, not 
including x-rays. This cost sharing is a contractual obligation that had not been met at the time the TTE with 
doppler was received on August 5, 2022.  At the time the claim was processed, you had a total of $223.13 remaining to meet the deductible. The $170 
copayment was then applied to the remainder of the charges, for a total of $393.13. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. Therefore, we decided that the Plan 
does not have to waive the deductible and copayment for a transthoracic echocardiogram (TTE) with doppler 
provided on August 5, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for two periodic oral evaluations and two prophylaxes provided from April 
1, 2019, to October 8, 2019. 
 
You asked the Plan to pay for the dental services. You say that you have been in contact with the Plan multiple 
times regarding these claims and you are appealing the denial for reimbursement. The Plan denied your 
request. The Plan says that the dental services were denied due to timely filing. 
 
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. The Plan says an Explanation of Benefits (EOB) for these services was sent to 
you on October 28, 2022, and you are appealing that denial. The Plan has failed to provide the EOB to support 
their denial. Therefore, we decided that the Plan has to pay for two periodic oral evaluations and two 
prophylaxes provided from April 1, 2019, to October 8, 2019.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital call (D9420) provided on August 3, 2022. 
 
You asked the Plan to pay for the dental service. You say that the dental service was necessary because you 
needed surgery. The Plan denied your request. The Plan says the denial of payment for this service is correct, 
because the hospital call is not covered by the 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. 
 
  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 hospital 
call (D9420) provided on August 3, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service October 28, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the member had multiple exams done on 
this date of service. 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 claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service October 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for debridement of nails provided on October 12, 2022. 
 
You asked the Plan to pay for debridement of nails. You say that these services were medically necessary. 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 debridement of nails 
provided on October 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body: endosteal implant 
(D6010 x8). 
 
You asked the Plan to pre-approve the surgical placement of implant body: endosteal implant (D6010 x8). You 
say that you need the dental implants in the front of your mouth as you are depressed and unable to eat. You 
also say that you are experiencing bleeding gums and weight loss. The Plan denied your request. The Plan says 
this service is not covered under the benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
surgical placement of implant body: endosteal implant (D6010 x8).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the seat lift mechanism (E0627) provided on January 6, 
2022. 
 
You asked the Plan to pay for the seat lift mechanism. You say that the durable medical equipment (DME) is 
medically necessary. The Plan denied your request. The Plan says the DME is not 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 pay for the seat lift mechanism. Our physician 
reviewer found the record indicates the enrollee does not have impaired ability to stand and walk because of 
arthritis of hip or knee or because of neurological disease. 
 
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 seat lift mechanism have not been met. Therefore, we decided that the Plan 
does not have to pay for the seat lift mechanism (E0627) provided on January 6, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on May 12, 2022, billed with 
codes 75630 and 75774. 
 You asked the Plan to pay for the medical services as billed. You say that these codes should be paid as they 
were billed with the necessary modifier. The Plan denied your request. The Plan says the use of the modifier 
for these Column 2 codes is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, we have confirmed that codes 75630 and 75774 are column II codes in relation to column I code 
37227; however, 75630 and 75774 were billed with a modifier.  
 
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 medical services as billed. Our reviewer says that the 
records do not support that separate payment should be made for the codes at issue. Our reviewer found for 
codes 75630 and 75774, the procedure report does support radiology procedures separate from the intervention 
performed, as interventional vascular procedures include operative angiograms/venograms. Therefore, modifier 
XU, unusual non-overlapping service, cannot be verified. This procedure would be inclusive to CPT 37227. 
 
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 medical services as billed have not been met. Therefore, we decided that the 
Plan does not have to pay for the medical services provided on May 12, 2022, billed with codes 75630 and 
75774.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. The Plan denied your request. The Plan says the enrollee does not 
require insulin three or more times daily. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic 
continuous glucose monitor (CGM).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76377 billed for date of service August 25, 
2022. 
 You asked the Plan to pay for procedure code 76377. You say that the enrollee had multiple exams on this date 
of service. You also say that you would like this to be reconsidered for processing. The Plan denied your 
request. The Plan says payment for code 76377 is bundled into payment for code 77290. 
 
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 76377 
is a column II code to column I code 77290. 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 76377 billed for date of service August 25, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for the routine venipuncture (36415), Sipuleucel-t (Q2043), and 
chemotherapy administration (96413) provided on March 22, 2021. 
 
You asked the Plan to pay for the routine venipuncture, Sipuleucel-t, and chemotherapy administration. You 
say that it is not stated in the Plan's policy that Provenge must be given at 2-week intervals. The Plan denied 
your request. The Plan says that this procedure code has been billed and allowed the maximum number of 
times within a particular period. 
 
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. The records do not support that these services have been billed and allowed the 
maximum number of times within a particular period. Specifically, there is nothing stating what the Plan 
believes correct number of units should be, or how the provider could correct the claim. This means that the 
Plan has not provided a valid reason for denying payment of the routine venipuncture, Sipuleucel-t, and 
chemotherapy administration. It is the burden of the Health Plan to substantiate their denial with evidence. In 
this case, the denial has not been substantiated so we must find in your favor. Therefore, we decided that the 
Plan has to pay for the routine venipuncture (36415), Sipuleucel-t (Q2043), and chemotherapy administration 
(96413) provided on March 22, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not meet the clinical requirements to be approved. 
 
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 pre-approve a 
crown (D2740)
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tradjenta tablets. 
 
You asked the Plan to pre-approve Tradjenta tablets. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says Tradjenta tablets are not covered under the enrollee's 
Medicare Part B 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 Tradjenta tablets.  
 
Benefits for Tradjenta tablets 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on 
September 28, 2022. 
 
You asked the Plan to pay for the dental service. You say that your new dentist required an evaluation, and it 
should be covered. 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 the date of service of December 28, 
2021. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on September 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the viable disc nucleus pulposus (NP) tissue allograft 
(0627T). 
 
You asked the Plan to pre-approve the procedure. You say that you are requesting a standard appeal for the 
denied L1/2 Via Disc. The Plan denied your request. The Plan says the clinical value and effectiveness of the 
viable disc nucleus pulposus tissue allograft in the setting of low back pain 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 looked at this the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve 
the viable disc nucleus pulposus (NP) tissue allograft (0627T).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular radiofrequency ablation. 
 
You asked the Plan to pre-approve genicular radiofrequency ablation. You say that the services are necessary. 
The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 genicular radiofrequency ablation. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found this approach is the 
subject of on-going clinical trials and is considered experimental at this time. Therefore, the request is deemed 
not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular radiofrequency ablation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve genicular radiofrequency ablation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that admission to IRF care is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for 
admission to an IRF. The enrollee's needs can be met at a lower level of care such as skilled nursing facility 
(SNF), home with home health services or home with outpatient therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there are no complex nursing or rehabilitation needs. While the enrollee has a need 
for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.