Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the extraction of tooth #4 (D7140) provided 
on January 18, 2022, adding tooth #4 and 5 to an existing partial denture (D5650) and endodontic therapy on 
tooth #6 (D3310) provided on February 3, 2022, and core build up on tooth #11 (D2950), a crown on tooth #11 
(D2740), and endodontic therapy on tooth #11 (D3310) provided on February 23, 2022. 
 
You asked the Plan to waive the cost share for the dental services. You say that the providers office should be 
held accountable for the damage to your health. 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 this benefit includes 
coverage up to $1,500 for preventive and comprehensive dental services. The contract also says the enrollee 
must pay 50% coinsurance for extractions, adding teeth to a partial denture, endodontic therapy, core build up, 
and crowns. 
 
You have been asked to pay 50% coinsurance of the allowed amount for each dental service received on 
January 18, 2022, and February 3, 2022, and core build up on February 23, 2022. The record shows your 
annual dental benefit was exhausted during the processing of the claim for date of service February 23, 2022. 
You are responsible for any amount above the benefit coverage limit.  
 
Date of Service Code Billed Amount Allowed Amount Cost Share Amount 
January 18, 2022 D7140 $183.00 $124.74 $62.37 
February 3, 2022 D5650 $241.00 $162.52 $81.26 
February 3, 2022 D5650 $241.00 $162.52 $81.26 
February 3, 2022 D3310 $843.00 $603.71 $301.86 
February 23, 2022 D2950 $340.00 $217.66 $108.83 
February 23, 2022 D2740 $1,373.00 $282.06 $798.27 
February 23, 2022 D3310 $843.00  $843.00 
 
These items/services fall within the dental 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 
cost share for the extraction of tooth #4 (D7140) provided on January 18, 2022, adding tooth #4 and 5 to an 
existing partial denture (D5650) and endodontic therapy on tooth #6 (D3310) provided on February 3, 2022, 
and core build up on tooth #11 (D2950), a crown on tooth #11 (D2740), and endodontic therapy on tooth #11 
(D3310) provided on February 23, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray of the chest provided to the enrollee on August 3, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Specifically, this claim was billed with the outpatient POS code. 
The records do not support that the x-ray was taken in an outpatient setting, as the enrollee appeared to be 
inpatient at the time. Therefore, we decided that the Plan does not have to pay for an x-ray of the chest 
provided to the enrollee on August 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on April 29, 2022. 
 
You asked the Plan to pay for the medical services. You say that the patient gave you incorrect insurance 
information, so you were unable to get 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 the medical services 
provided on April 29, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an ultrasound provided on March 25, 
2022. 
 
You asked the Plan to reduce the copayment for an ultrasound. You say that you should only have a $50 
copayment. 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 $125 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $125 copayment for an ultrasound. This item/service falls 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.You have been asked to pay the allowed amount of $86.36 which 
is less than the $125 copayment for an ultrasound. Therefore, we decided that the Plan does not have to reduce 
the copayment for an ultrasound provided on March 25, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the eyes, fact, 
neck, chest, and pelvis. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the medical records do not show that a previous computed tomography (CT) scan was 
negative, or that there was not already a diagnosis of myeloma. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 services. Our reviewer says that the 
requested imaging services are not medically reasonable or necessary. Our physician reviewer found that the 
enrollee had total positron emission tomography/computed tomography (PET/CT) including diagnostic total 
body CT on 12/13/22. The exam revealed multiple expansile and lytic lesions throughout the body consistent 
with multiple myeloma. These lytic lesions are not only evident on the diagnostic total body CT they are 
metabolically active; ie 18FDG avid. The impression of this exam was to continue to monitor the lesions for 
possible developing pathologic fracture. The rationale for the requested multiple MRI studies is not well 
explained. The original appeal stated analysis was for possible unexpected developing fractures. The PET scan 
and importantly the total body diagnostic CT scan offered what seems to be adequate assessment of the 
multiple lytic and PET avid lesions. Absent a more detailed explanation of the need for the additional requested 
MRI studies in this patient with straightforward findings of polyostotic multiple myeloma visible on both PET 
and diagnostic CT is not medically 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve magnetic resonance imaging (MRI) of the eyes, fact, neck, chest, and pelvis.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76700 billed for date of service July 14, 
2022. 
 
You asked the Plan to pay for procedure code 76700. You say that this was not a bundled charge. The Plan 
denied your request. The Plan says payment for code 76700 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 76700 
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 76700 billed for date of service July 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76140 billed for date of service July 29, 
2022. 
 
You asked the Plan to pay for procedure code 76140. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 76140 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 76140 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 76140 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 76140 billed for date of service July 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial upper denture (D5225). 
 
You asked the Plan to pre-approve the dental services. You say that your old denture is causing you pain and 
you need a new one. 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 July 29, 2022. Therefore, 
we decided that the Plan does not have to pre-approve a partial upper denture (D5225).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgery to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve surgery. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollee must receive their care from a network provider (for more information 
about this, see Section 2 in this chapter). In most cases, care the enrollee receives from an out-of-network 
provider (a provider who is not part of our plans network) will not be 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
surgery to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ankle foot orthosis (AFO) (L1951). 
 
You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says you do not meet criteria for coverage of the requested item. 
 
The Plan must follow Medicare rules. Medicare rules say that replacement of equipment due to irreparable 
wear takes into consideration the reasonable useful lifetime (RUL) of the equipment. In the absence of program 
instructions, Medicare contractors may determine the reasonable useful lifetime of equipment, but in no case 
can it be less than 5 years. Replacement due to wear is not covered during the reasonable useful lifetime of the 
equipment.  
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of this item have not been met. Specifically, the rules say that replacement of equipment due to 
irreparable wear takes into consideration the reasonable useful lifetime (RUL) of the equipment. Medicare 
contractors may determine the reasonable useful lifetime of equipment, but in no case can it be less than 5 
years. The record indicates that you received this device previously in 2020, which is less than 5 years ago. 
Therefore, you do not meet criteria for coverage of the requested item. Therefore, we decided that the Plan does 
not have to pre-approve an ankle foot orthosis (AFO) (L1951).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgery to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve surgery. 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
surgery to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that you need this surgery. The Plan 
denied your request. The Plan says this surgery as approved as an ambulatory procedure and reconsideration 
for inpatient level of care can be given if you experience any complications. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that you do not meet criteria for inpatient hospital level of care. Our physician reviewer found the 
documentation does not clearly demonstrate that you have an unstable condition or are at high risk of complication or prolonged recovery in the hospital to support inpatient services for this typically ambulatory 
surgery. The documentation does not suggest that your care will span at least 2 midnights in the hospital. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya. 
 
You asked the Plan to pre-approve the drug. You say that Ilumya is medically appropriate and necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not have any stated contraindications 
to, nor have they tried, the preferred products. The Plan also says a rationale for use of the non-preferred 
product for safety or efficacy was not provided. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found that there is no 
indication of a trial and failure of Enbrel, Humira, Otezla, or Skyrizi. Based on the medical records provided, 
and the Medicare-approved major drug compendia there is no indication that the plan's required drugs would 
likely be less effective and/or likely have adverse effects for the enrollee. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Ilumya.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services provided from April 25, 2022, 
through April 26, 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 are not payable as the provider is 
not enrolled in the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the outpatient services provided from 
April 25, 2022, through April 26, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve the PET scan. You say that it is medically necessary that the enrollee gets a 
PET scan. The Plan denied your request. The Plan says the medical records provided do not indicate that the 
enrollee meets the diagnostic criteria of both Alzheimer's disease and fronto-temporal dementia. There is no 
indication that the exam is being requested in the context of a clinical trial. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
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 PET scan. Our reviewer says that 
the PET scan is not medically necessary. Our physician reviewer found that the records provided for review 
only suggested that the enrollee has Alzheimers disease and that a diagnosis of AD was made on clinical 
grounds. As the enrollee does not meet diagnostic criteria for both AD and FTD (and only one of the conditions 
is suspected), this request would not meet the requirements of the NCD for provision of this service. 
 
  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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-network. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. 
Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodic comprehensive preventive medicine services 
provided on October 20, 2021. 
 
You asked the Plan to pay for periodic comprehensive preventive medicine services. You say that the medical 
group used the same billing code as your primary doctor. The Plan denied your request. The Plan says the 
claim exceeds the benefit maximum. The annual physical examination coverage was used last on  
February 9, 2021. 
 
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once 
every 12 months.  
 
Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. 
Therefore, we decided that the Plan does not have to pay for periodic comprehensive preventive medicine 
services provided on October 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that you are appealing the denied 
service. The Plan denied your request. The Plan says the LDCT of the chest is reasonable or necessary at this 
time and the Plan recommends a standard diagnostic computerized tomography scan. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
  We reviewed the file and the Medicare rules. We found that the documentation shows the enrollee is 78 years 
old; therefore, the age criteria for the NCD is not met. Therefore, we decided that the Plan does not have to pre-
approve a low dose computed tomography (LDCT) scan for lung cancer screening.