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

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B prescription drugs 
provided on October 14, 2022. 
 
You asked the Plan to waive the coinsurance for Medicare Part B prescription drugs. You say that you disagree 
with the coinsurance. 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a 20% coinsurance for Medicare Part B prescription drugs. The total allowed 
amount for the prescription drugs is $12,647.40 ($12,647.40 x 20% = $2,529.48). However, you hit your out-
of-pocket maximum so you are only responsible $1,421.14. This item/service falls within the Medicare Part B 
prescription drugs benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for Medicare Part B 
prescription drugs provided on October 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a therapeutic continuous glucose monitor (CGM) provided 
on May 25, 2022. 
 
You asked the Plan to pay for the CGM. 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. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
 
  The record does not contain a valid physician order, proof of delivery, or relevant medical records which 
support medical necessity for the supplies provided in this case. The record shows that the Plan made several 
attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not 
have to pay for a therapeutic continuous glucose monitor (CGM) provided on May 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the expandable controller (E2377), harness (E2313), 
and electronic connection (E2311). 
 
You asked the Plan to pre-approve the expandable controller, harness, and electronic connection. You say that 
the items are medically necessary. The Plan denied your request. The Plan says the items are not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the expandable controller, harness, and 
electronic connection. Our reviewer says that the requested items are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has 5/5 right upper extremity strength with no 
functional limitations of the right hand or wrist thus indicating he has adequate right upper extremity strength 
and function to operate the wheelchair's power options with their own switches.  
 
 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 expandable controller, harness, and electronic connection have not been 
met. Therefore, we decided that the Plan does not have to pre-approve the expandable controller (E2377), 
harness (E2313), and electronic connection (E2311).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206) provided 
on September 30, 2020. 
 
You asked the Plan to pay for the topical application of fluoride varnish (D1206). You say that you believe that 
this provider is a contracting provider to the Plan. The Plan denied your request. The Plan says the topical 
application of fluoride varnish (D1206) is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
topical application of fluoride varnish (D1206) provided on September 30, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient mental health visit provided on August 11, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an outpatient mental health visit. You say that the reports attached support the 
services provided. The Plan denied your request. The Plan says there is no prior authorization on file for the 
services rendered. 
 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an outpatient mental health visit provided on 
August 11, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown on tooth #11 (D2740) and a partial maxillary 
denture (D5211) provided on August 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of the dental 
services. The Plan denied your request. The Plan says your benefit for the requested items or services 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 items or services was exhausted on date of service August 16, 2022. 
Therefore, we decided that the Plan does not have to pay for a crown on tooth #11 (D2740) and a partial 
maxillary denture (D5211) provided on August 29, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the osteopathic manipulation treatment billed with code 98927 for July 
18, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says that the provider did not bill according to Medicare guidelines. 
 
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 states that code 98927 was not billed per Medicare guidelines; 
however, further documentation or explanation is not provided. The Plan has not provided any binding 
Medicare rules to support that the code is not payable as billed. Therefore, we decided that the Plan has to pay 
for the osteopathic manipulation treatment billed with code 98927 for July 18, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) and the 
extraction, of an erupted tooth requiring removal of bone and/or sectioning of tooth (D7210) provided on  
June 2, 2022. 
 
You asked the Plan to pay for these dental 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 benefit for the panoramic 
radiographic image has already been exhausted. Additionally, the extraction of an erupted tooth is not a 
covered benefit.  
 
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 that the benefit for the panoramic radiographic image provided was exhausted on date of service  
August 10, 2020.  Specifically, the Plan contract states that a panoramic radiographic image is covered once every three years. 
You previously received this service on August 10, 2020, which was paid for by the Plan. Therefore, you have 
exhausted the allowable benefit for this service. Additionally, the extraction of an erupted tooth is not a covered 
benefit under your contractual policy. Therefore, we decided that the Plan does not have to pay for the 
panoramic radiographic image  (D0330) and the extraction, of an erupted tooth requiring removal of bone 
and/or sectioning of tooth (D7210) provided on June 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tomography procedure (76497), unlisted craniofacial 
procedure (21299), joint survey (77077), nasal function study (92512), laryngeal function studies (92520), 
physical performance test (97750), and office visit provided from June 6, 2022, to June 8, 2022. 
 
You asked the Plan to pay for the physician services. You say that you dislocated your jaw. You say that you 
saw several doctors for your pain with no improvement. You say that your friend referred you to this provider. 
You also say that the previous doctors you saw were reimbursed. The Plan denied your request. The Plan says 
the provider in this case has opted out of Medicare. The Plan also says that payment cannot be made for 
services that you received from a provider that has opted out of Medicare. 
 The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
tomography procedure (76497), unlisted craniofacial procedure (21299), joint survey (77077), nasal function 
study (92512), laryngeal function studies (92520), physical performance test (97750), and office visit provided 
from June 6, 2022, to June 8, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 31, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the member had multiple exams done on 
this date of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into 
payment for code 70496. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Column I code was billed on a seperate claim for the same date of service. Based on the claims 
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 70450 billed for date of service October 31, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 20930, 20936, 61783, and 69990 billed for 
date of service April 21, 2022. 
 
You asked the Plan to pay for procedure codes 20930, 20936, 61783, and 69990. 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 providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure codes 20930 and 20936 have a status indicator of B on the Physician Fee Schedule. 
This means that procedure codes 20930 and 20936 are not separately payable.  
 
Additionally, we have confirmed that code 61783 is a column II code to column I code 63052. This claim has 
not been billed with an appropriate modifier to bypass the edit.  
 
Lastly, we have confirmed that code 69990 is a column II code to column I code 63052 with a modifier 
indicator of 0. The column II code is therefore not payable. 
 
Based on this information, we decided that Medicare rules for coverage of procedure codes 20930, 20936, 
61783, and 69990 have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
codes 20930, 20936, 61783, and 69990 billed for date of service April 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 11104 billed for date of service August 29, 2022.

You asked the Plan to pay for procedure code 11104. You say that you disagree with the Plan's denial. 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 cannot be paid when the MAI value is 2. The rules also state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.

In this case, the MUE for CPT code 11104 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. While one unit was billed with modifier -59, the medical records provided do not show that the service billed with the -59 modifier is a distinct procedural service. Based on this information, we decided that Medicare rules for coverage of procedure code 11104 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 11104 billed for date of service August 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation and intraoral x-ray (D0150, 
D0210) provided on May 26, 2022. 
 
You asked the Plan to pay for 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 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 December 2, 2020. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation and intraoral x-
ray (D0150, D0210) provided on May 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete mandibular denture (D5120) provided on March 
28, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are requesting payment for this. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your $1,500 allowance was exhausted on date of service March 28, 2022. Therefore, we decided that the 
Plan does not have to pay for a complete mandibular denture (D5120) provided on March 28, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a capsule endoscopy (91110). 
 
You asked the Plan to pre-approve a capsule endoscopy. You say that you would like to avoid a colonoscopy 
based on the enrollee's age and cardiac history. You also say that you would like to proceed with a capsule. The 
Plan denied your request. The Plan says the requested capsule endoscopy requested (91110) does not meet the 
requirements for approval. 
 
The Plan follows Medicare rules. Medicare rules say that Medicare expects repeat wireless capsule endoscopic 
studies for any patient to be for medically reasonable and necessary clinical circumstances consistent with 
accepted standards of medical practice and that the medical records demonstrate such. 
 
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 capsule endoscopy. Our physician 
reviewer found the enrollee does not meet the coverage criteria for a negative colonoscopy within 1 year. Our 
reviewer found that the enrollee's last colonoscopy on November 11, 2020, would be considered incomplete 
due to the inadequacy of their preparation. Our physician reviewer also found that the request for a second 
capsule endoscopy at this time is not medically reasonable and necessary prior to an adequately prepared and 
complete colonoscopy study. 
 
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 capsule endoscopy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a capsule endoscopy (91110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental extractions (D7140) provided on August 2, 2022, to 
August 25, 2022. 
 
You asked the Plan to pay for 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 fall 
within your dental 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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for dental 
extractions (D7140) provided on August 2, 2022, to August 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia (D9222 and D9223), and extractions (D7210) 
provided on October 27, 2022. 
 
You asked the Plan to pay for anesthesia and extractions. You say that these services are medically necessary. 
The Plan denied your request. The Plan says the rendered 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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for anesthesia 
(D9222 and D9223), and extractions (D7210) provided on October 27, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a myocardial perfusion imaging, single-photon emission 
computerized tomography (SPECT) (78452). 
 
You asked the Plan to pre-approve a SPECT scan. You say that a new myocardial perfusion imaging is 
recommended. The Plan denied your request. The Plan says this request is not medically necessary because the 
records do not show that the enrollee has any cardiac symptoms or any of the other covered indications. 
 
The Plan follows Medicare rules. Medicare rules say that stress testing with cardiac imaging will be considered 
medically reasonable and necessary for patients experiencing new, recurrent, or worsening cardiac symptoms, 
including otherwise unexplained angina equivalent symptoms, a new or previously unrecognized 
uninterpretable electrocardiogram (ECG). 
 
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 SPECT scan. Our reviewer says that 
there is insufficient documentation to support the medical necessity for the requested SPECT imaging in this 
enrollees clinical management. Our physician reviewer found the enrollee had a cardiac catheterization in 
2019, has had no cardiac symptoms at visits in May of 2022, and October of 2022, with a normal 
echocardiogram in November 2022. There is no documentation that the ECG shows an uninterpretable pattern. 
Our reviewer found that here is no evidence provided that would support the need for radionuclide stress 
testing at this time. 
 
 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 SPECT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a myocardial perfusion imaging, single-photon emission computerized tomography 
(SPECT) (78452).