Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a re-evaluation, post-operative office visit (D0171). 
 
You asked the Plan to pre-approve dental service. You say that the reevaluation is part of the initial problem 
due to an infection. The infection needs to be treated. The Plan denied your request. The Plan says this service 
is not included as 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 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 re-
evaluation, post-operative office visit (D0171).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection services provided on February 11, 2022. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the code was 
not billed correctly. 
 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.  
 
In this case, the MUE for CPT code 64494 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the 
services provided have not been met. Therefore, we decided that the Plan does not have to pay for the injection 
services provided on February 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on February 17, 2022 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the wound care supplies. You say that these supplies are separately payable and 
shouldn't require a separate authorization. The Plan denied your request. The Plan says items received from an 
out-of-network provider without authorization are 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 in this case is not a network provider with the Plan. TThe Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for wound care supplies provided on February 17, 
2022 by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) evaluation provided on 
January 6, 2022, billed with code 99285. 
 
You asked the Plan to pay for the ED services as billed. You say that you believe that the medical records 
support the use of 99285. The Plan denied your request. The Plan says the records support a lower level ED 
evaluation as described by 99284 which was paid by the Plan. 
 
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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and medical decision making of high complexity. Counseling and/or coordination of care with 
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature 
of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function. 
 
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 ED services as billed. Our reviewer says 
that the reported code is not supported by the medical records. Our reviewer found the enrollee is a male with a 
history of kidney stones who was seen in the ED for left flank pain. However, the workup revealed non-
obstructing calculi, and no invasive intervention was recommended or provided. He was given intravenous 
antibiotics, pain medications, and anti-nausea medication and was discharged on oral antibiotics. Vitals 
remained stable. Due to the lower complexity and risk of the treatment in the ED, code 99284 is more 
appropriate. The documentation does not support the reporting of code 99285 for the emergency services 
rendered. 
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the ED services as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the emergency department (ED) evaluation provided on January 6, 2022, billed with 
code 99285.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prednisone. 
 
You asked the Plan to pre-approve Prednisone. You say that Prednisone will allow the enrollee a better quality 
of life. The Plan denied your request. The Plan says the request of Prednisone for undifferentiated 
inflammatory arthritis falls under Part D, and is not covered under Part B. 
 
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 Prednisone.  
 
Benefits for Prednisone 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-one (J7326). 
 
You asked the Plan to pre-approve Gel-one. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B step therapy criteria for the requested viscosupplement device. 
 
 
 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 Gel-one. Our reviewer says that Gel-
one is not medically reasonable and necessary for the enrollee. Our physician reviewer found the enrollee has 
not tried and failed the Plan's required drugs, Durolane, Monovisc, or Synvisc-One. Our reviewer also found 
that the documentation does not support that Durolane, Monovisc, or Synvisc-One would likely be less 
effective, and/or would likely have adverse effects for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gel-one have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-one (J7326).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on March 21, 2022. 
 
You asked the Plan to pay for the ambulance service. You say that the paramedics advised you could either be 
taken to the hospital or have someone else drive you. You say that you were not advised that you would be 
billed for choosing not to ride in the ambulance. You also say that you feel this should be covered. The Plan 
denied your request. The Plan says since there was no transport provided, there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 21, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport, (A0998) provided on March 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 4, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed codes 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that 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. The claim in this  case was billed with the laboratory POS code. The 
records do not support that the sample was taken in a laboratory setting. Based on this information, we decided 
that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan 
does not have to pay for lab services provided on November 4, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service April 7, 
2022. 
 
You asked the Plan to pay for procedure code 76705. The Plan denied your request. The Plan says payment for 
code 76705 is bundled into payment for code 93976.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76705 billed for date of service April 7, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hyperbaric oxygen therapy provided on March 1, 2021, to 
March 12, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for hyperbaric oxygen therapy. You say that these services were medically 
necessary. The Plan denied your request. The Plan says services provided by an out-of-network provider are 
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 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 hyperbaric oxygen therapy provided on March 1, 
2021, to March 12, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve computed tomography (CT) scan of the chest for the enrollee. 
 
You asked the Plan to pre-approve the scam. You say that this is medically necessary. The Plan denied your 
request. The Plan says that clinical notes showing the reason for this test are needed. 
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 scam. Our reviewer says that the 
requested scan is medically reasonable and necessary. Our physician reviewer found that the prior computed 
tomography (CT) revealed multiple abnormal findings, including ground glass nodular changes, which would 
represent inflammatory changes or metastatic disease. The oncologist is treating the patient with chemotherapy 
and the notes show a plan to have the CT done prior to his next visit which is scheduled to be 9/2/22. The 
requested exam is reasonable and should be approved. 
 
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 scam have been met. Therefore, we decided that the Plan has to pre-approve 
computed tomography (CT) scan of the chest for the enrollee.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74176 billed for date of service May 1, 2022. 
 
You asked the Plan to pay for procedure code 74176. The Plan denied your request. The Plan says payment for 
code 74176 is bundled into payment for code 74177. 
 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 74176 
is a column II code to column I code 74177. 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 74176 billed for date of service May 1, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve skin grafting with Palingen/Palingen XPlus. 
 
You asked the Plan to pre-approve skin grafting with Palingen/Palingen XPlus. You say that the services are 
necessary. The Plan denied your request. The Plan says that medical necessity has not been established. 
Therefore, coverage criteria 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 skin grafting with Palingen/Palingen 
XPlus. Our reviewer says that the requested items/services are considered medically reasonable and necessary 
in this case. Our physician reviewer found in this particular case the enrollee is noted to be suffering with a 
nonhealing wound to the right foot that has not responded to appropriate wound care. Amniotic membranes are 
FDA approved for application to nonhealing wounds. PalinGen and PalinGen XPlus are FDA approved 
amniotic membrane wound applications. Therefore, it is my opinion that the skin grafting with PalinGen and 
PalinGen XPlus to this enrollees right foot wound is 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 skin grafting with Palingen/Palingen XPlus have been met. Therefore, we 
decided that the Plan has to pre-approve skin grafting with Palingen/Palingen XPlus.  
 
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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the brain for the enrollee. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the records do not show a diagnosis of dementia. 
 
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 MRI. Our reviewer says that the 
requested MRI is medically reasonable and necessary. Our physician reviewer found that the enrollee has 
documented memory loss. There was a detailed neurological workup including Mini-Mental State Examination 
(MMSE) and other testing as well as corroboration of problems from others. The likely diagnosis of 
Alzheimer's dementia. Given her workup the request for MRI of the brain is reasonable and should be 
approved. 
 
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
magnetic resonance imaging (MRI) of the brain for the enrollee.  
 
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 removal of torus mandibularis (CPT code D7473). 
 
You asked the Plan to pre-approve the dental services. You say that the service is necessary. The Plan denied 
your request. The Plan says the service is not a covered benefit under 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.  The service is not listed in your EOC as a covered benefit; therefore, the services are not 
covered. Therefore, we decided that the Plan does not have to pre-approve removal of torus mandibularis (CPT 
code D7473).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the substance abuse services rendered on February 6, 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 the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that substance abuse facilities are not eligible to participate 
in Medicare. 
 
We looked at the file and Medicare rules. The file shows that the services at issue were rendered by a substance 
abuse facility. Therefore, we decided that the Plan does not have to pay for the substance abuse services 
rendered on February 6, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided 
from February 26, 2022, to February 28, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say please cover this $246 
charge from the hospital. The Plan denied your request. The Plan says you have been charged the correct cost 
sharing amount. 
 
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 $240 
copayment per day for days 1-5 for Inpatient Hospital Care.  
 
You have been asked to pay a $240 copayment for the inpatient hospital services. The inpatient hospital 
services fall within the Inpatient Hospital 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 the inpatient hospital services provided from February 26, 2022, to February 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fitting/orientation/checking of hearing aid (V5011), 
repair/modification of a hearing aid (V5014), and ear impression (V5275) provided on October 19, 2021, and 
December 13, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the hearing aid services. You say that you were advised by the Plan to follow up 
on the next step to get your other insurance to apply and pay for these bills. The Plan denied your request. The 
Plan says the hearing aids must be purchased through the Plan's approved hearing aid vendor, and you must 
register with them prior to receiving the hearing aids. The Plan also says that these services were rendered by a 
provider who is not part of the Plan's hearing vendor network. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when you use the Plan's hearing aid vendor to use your hearing aid benefits. 
 
 
 We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aid services have not been met. Therefore, we decided that the Plan does not have to 
pay for the fitting/orientation/checking of hearing aid (V5011), repair/modification of a hearing aid (V5014), 
and ear impression (V5275) provided on October 19, 2021, and December 13, 2021, by an out-of-network 
(OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy duty walker and seat attachment. 
 
You asked the Plan to pre-approve a heavy duty walker and seat attachment. You say that the items are 
necessary. The Plan denied your request. The Plan says the benefit has been exhausted. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a heavy duty walker and seat attachment. The items you have serve the same 
purpose as the requested items. You received a heavy duty walker on June 15, 2022 and a seat attachment on 
June 9, 2022. Therefore, we decided that the Plan does not have to pre-approve a heavy duty walker and seat 
attachment.