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

 
We decided that the Plan does not have to pay for a periodontal maintenance (D4910) and an intraoral 
periapical radiographic image (D0220) provided by an out-of-network provider on March 2, 2021, to June 3, 
2021. 
 
You asked the Plan to pay for a periodontal maintenance and an intraoral periapical radiographic image. You 
say that you were never informed that this provided opted-out of Medicare. The Plan denied your request. The 
Plan says the claim for these services has been correctly denied. 
 
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. The physician who provided these services has opted-out of Medicare. Therefore, we decided that the Plan does not have to pay for a periodontal maintenance (D4910) and an 
intraoral periapical radiographic image (D0220) provided by an out-of-network provider on March 2, 2021, to 
June 3, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says you do not meet requirements for an IRF admission. 
 
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 that the complexity of your nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for 
physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 
rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a Transcutaneous electrical nerve stimulation (TENS) device 
purchased on May 14, 2021. 
 
You asked the Plan to pay for this device. You say that this device is medically necessary and should be 
covered by the Plan. The Plan denied your request. The Plan says you did not have prior authorization for this 
purchase and this device is not covered for chronic low back pain. 
 
The Plan must follow Medicare rules. Medicare does not cover this device for chronic low back pain. The Plan 
contract says that durable medical equipment requires prior authorization. You purchased this equipment out of 
network, without prior authorization. The records how you have chronic low back pain, and therefore this 
device would not be covered by Medicare. Therefore, we decided that the Plan does not have to pay for a 
Transcutaneous electrical nerve stimulation (TENS) device purchased on May 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and a 2D 
oral/facial photographic image (D0350) provided on June 28, 2021, by a non-participating provider. 
 
You asked the Plan to pay for a comprehensive oral evaluation and a 2D oral/facial photographic image. You 
say that you went to the dentist and was told that you had several cavities that required dental work. When you 
went back, another provider contradicted the last provider. You were concerned so you looked for a second 
opinion and the provider found several cavities. Prior to the dental work, the evaluation and images are 
required. You are requesting the Plan to reconsider payment to the provider. The Plan denied your request. The 
Plan says you receive one comprehensive exam every three years. The Plan also says that a 2D oral/facial 
photographic image is not a covered service with your Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. The Plan covers a 
comprehensive oral evaluation once every three years and a 2D oral/facial photographic image is not a covered 
benefit.  
 We looked at the file and Medicare rules. The records show that you received a comprehensive oral evaluation 
on November 3, 2020, therefore, you have exhausted your maximum benefit for this service. The EOC 
confirms that a 2D photographic image is not a covered service under your benefit Plan. Based on this 
information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation and a 2D 
oral/facial photographic image have not been met. Therefore, we decided that the Plan does not have to pay for 
a comprehensive oral evaluation (D0150) and a 2D oral/facial photographic image (D0350) provided on June 
28, 2021, by a non-participating provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for triiodothyronine testing (84480) provided on November 5, 
2020. 

You asked the Plan to pay for triiodothyronine testing. You say that this should be covered. The Plan denied 
your request. The Plan says this is not separately payable. 
 
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 84480 is a column II code to column I code 84481. 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 triiodothyronine testing (84480) provided on November 5, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the brain.

You asked the Plan to pre-approve an MRI. You say that you recently had a severe case of COVID-19. You have tried going through the primary care physician to have the services coordinated but the doctor is refusing stating you do not need the services. The Plan denied your request. The Plan says the medical information provided does not support that the MRI is medically necessary.

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 an MRI. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no specific clinical rationale for the requested MRI of the brain and the requested MRI is not medically reasonable or 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 an MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the brain.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapy services provided on July 27, 2020.

You asked the Plan to pay for the therapy services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.

The Plan must follow Medicare rules. Medicare rules say that the services of a PTA shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy have not been met. Specifically, the billing provider is a nurse practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's professional services.

Therefore, we decided that the Plan does not have to pay for the therapy services provided on July 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit for physician's services 
provided on January 12, 2021. 
 
You asked the Plan to waive the copayment for the office visit. The Plan denied your request. The Plan says the 
claim processed with the correct copayment. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 
copayment for Medicare vision services, specialist office. 
 
You have been asked to pay a $25 copayment for the office visit. The office visit falls within the Vision Care benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for an office visit for physician's 
services provided on January 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), prophylaxis 
(D1110), and topical application of fluoride varnish (D1206) provided on June 23, 2021. 
 
You asked the Plan to pay for the comprehensive oral evaluation, prophylaxis, and topical application of 
fluoride varnish. You say that you cannot pay this bill. The Plan denied your request. The Plan says your 
annual maximum 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 Plan?s coverage rules apply in this case.  
Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan offers a $1,500 annual dental 
benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are 
responsible for the full charges of any additional dental services] The record shows that you met the annual 
maximum benefit on February 8, 2021 and your annual maximum benefit has been exhausted. Therefore, we 
decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), prophylaxis 
(D1110), and topical application of fluoride varnish (D1206) provided on June 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing provided on May 11, 2021. 
 You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the records do 
not show extensive testing was necessary for treatment. 
 
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, the CPT Code Manual definition of code G0483 is definitive drug testing of 22 or more drug 
classes. We find that CPT code G0483 is not supported in the medical record. Specifically, the records 
provided do not show that testing of 22 or more drug classes was needed due to medication side effects or 
inefficacy, suspicious behaviors, self-escalation of dose, doctor-shopping, indications/symptoms of illegal drug 
use, evidence of diversion, or other clinician documented change in affect or behavioral pattern. Based on this 
information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, 
we decided that the Plan does not have to pay for the definitive drug testing provided on May 11, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a CardioMEMS device (33289). 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that the requested item is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says that medical necessity rules for the 
requested item have not been met. 
 
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 a CardioMEMS device. Our reviewer 
says that the requested item is considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee has severe heart failure with depressed ejection fraction (EF) and is on 
appropriate guideline-directed chronic heart failure (CHF) medications with recurrent and recent 
hospitalizations for CHF within the past year. Management of the enrollee's heart failure with standard medical 
therapy and relying on symptoms and signs has not been effective in keeping the enrollee with minimal 
symptoms and has resulted in acute hospitalizations. CardioMEMS device monitoring in this situation can 
provide additional heart filling pressure data to better manage complex diuretic and vasodilator regimens. 
Given the severe symptoms of recurrent CHF which appear sensitive to volume loading conditions, the 
complexity of the medical regimen, and the failure to prevent acute CHF hospitalization in this patient, use of 
the CardioMEMS device is reasonable and has clinical data, expert opinion, and approved Food and Drug 
Administration (FDA) indications to back up its use in selected appropriate clinical situations like that of 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 a CardioMEMS device have been met. Therefore, we decided that the Plan has 
to pre-approve a CardioMEMS device (33289).  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy 
assistant on March 15, 2021. 
 
  You asked the Plan to pay for the physical therapy services. You say that plans are required to pay non-
contracted providers at the preferred provider rate if services are not available from preferred providers. You 
say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your 
request. The Plan says the records do not support the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (PTA) 
shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they 
do not meet the qualifications of a therapist. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the physical therapy services have not been met. Specifically, the billing provider is a nurse 
practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's 
professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services 
provided by a physical therapy assistant on March 15, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve myocardial strain imaging (93356). 
 
You asked the Plan to pre-approve the diagnostic service. You say that you are appealing the denial of the 
myocardial strain. The Plan denied your request. The Plan says that the request for myocardial strain imaging is 
not medically necessary. 
 
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 diagnostic service. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee meets some criteria for possible amyloid heart disease and there remains 
a good deal of uncertainty regarding the role recurrent aortic valve disease. Diastolic dysfunction may be 
playing in her symptoms (most recently recurrent chest discomforts). Trying to rule out early occult amyloid 
heart disease as an etiology is reasonable and medically necessary. Strain imaging has been shown to have 
reasonable diagnostic sensitivity in several conditions (especially amyloid) in addition to just following patients 
previously treated with cardiotoxic agents or radiation. Strain imaging in addition to standard echocardiography 
increases the sensitivity and specificity of an amyloid diagnosis (1,2) and would therefore be a reasonable and 
medically necessary non-invasive way of differentiating early amyloid heart disease from standard left 
ventricular hypertrophy and diastolic dysfunction in this enrollee who meets both the age and some of the 
clinical criteria and would therefore meet the medical reasonableness and necessity requirements.  
 
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 diagnostic service have been met. Therefore, we decided that the Plan has to 
pre-approve myocardial strain imaging (93356).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dermatology visit, and services provided on September 9, 
2020, by an OON provider. 
 
You asked the Plan to pay for the dermatology visit and services. You say that the enrollee stated there were no 
changes to their insurance. You say the services were provided in good faith. The Plan denied your request. 
The Plan says no prior authorization was obtained. 
 
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 did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the services at issue were urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the dermatology visit, and services provided on September 9, 
2020, by an OON provider.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve ascending aorta graft and replacement aortic valve services. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says that the 
records only show mild to moderate mitral insufficiency and no symptoms. 
 
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 requested services. Our physician 
reviewer found that in this case, the record indicates the enrollee has a 5.0 cm ascending aortic aneurysm, 4.4 
cm at the aortic root, and moderate aortic insufficiency with dyspnea upon exertion working in garden for 
fifteen minutes. The echocardiogram also shows mild left ventricular cavitary dilation. The enrollee believes 
that it is due to his lung disease. The cardiac surgeon believes his dyspnea is due to worsening cardiac anatomy 
and that repair is appropriate at this time. The records provided establish the medical necessity and 
reasonableness, as defined by Medicare rules, of the requested 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 requested services have been met. Therefore, we decided that the Plan has to 
pre-approve ascending aorta graft and replacement aortic valve services.  
 
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics (L3000) provided on May 12, 2021. 
 
You asked the Plan to pay for foot orthotics. You say that it will be a hardship for you to pay the cost of the 
foot orthotics at issue. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics (L3000) provided on May 
12, 2021.