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

 
We decided that the Plan does not have to pay for a binaural, digital hearing aid (V5261) provided on June 28, 
2022. 
 
You asked the Plan to pay for a binaural, digital hearing aid (V5261). You say that looking at the book sent to 
retirees, it states that hearing aids are covered and benefits are combined in and out-of-network. The Plan 
denied your request. The Plan says the hearing benefit is not covered if the services are not registered in 
advance and authorized. 
 
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 the hearing aids are ordered through a Plan provider.  
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of a binaural, digital hearing aid (V5261) have not been met. Therefore, we decided that the Plan does 
not have to pay for a binaural, digital hearing aid (V5261) provided on June 28, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for ambulance service provided on August 9, 
2022. 
 
You asked the Plan to waive the cost share for ambulance service. You say that you are disputing the share 
cost. 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 $310.01 
deductible for ambulance services.  
 
You have been asked to pay $310.01 deductible for ambulance service. This item/service falls within the 
ambulance 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 ambulance service 
provided on August 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve paravertebral facet joint block, lumbar/sacral 3 levels. 
 
You asked the Plan to pre-approve paravertebral facet joint block, lumbar/sacral 3 levels. You say that 
paravertebral facet joint block, lumbar/sacral 3 levels is medically necessary. The Plan denied your request. 
The Plan says there were no notes showing a minimum of 3 months of non-surgical management. 
 
The Plan follows Medicare rules.  
 
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 paravertebral facet joint block, 
lumbar/sacral 3 levels. Our reviewer says that paravertebral facet joint block, lumbar/sacral 3 levels is not 
medically necessary. Our physician reviewer found that in this case, there is documentation of radiculopathy.  
The review has determined that the requested facet joint injections do not meet the Medicare LCD coverage 
criteria.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of paravertebral facet joint block, lumbar/sacral 3 levels have not been met. 
Therefore, we decided that the Plan does not have to pre-approve paravertebral facet joint block, lumbar/sacral 
3 levels.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 64991 and 64492 billed for date of service 
May 5, 2022. 
 
You asked the Plan to pay for procedure codes 64991 and 64492. You say that the services at issue have been 
billed correctly. 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.  
 
In this case, the MUE for CPT codes 64991 and 64492 is 1. The MAI value for these codes is 2. You billed 2 
units of each of these codes, exceeding the MUE. Based on this information, we decided that Medicare rules 
for coverage of procedure codes 64991 and 64492 have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure codes 64991 and 64492 billed for date of service May 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve posterior tibial nerve stimulation. 
 
You asked the Plan to pre-approve posterior tibial nerve stimulation. You say that posterior tibial nerve 
stimulation is medically necessary. The Plan denied your request. The Plan says posterior tibial nerve 
stimulation is 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 posterior tibial nerve stimulation. Our 
reviewer says that the requested posterior tibial nerve stimulation is not considered medically reasonable and 
necessary. Our physician reviewer found that the records do not show that the enrollee has failed behavior 
modification and pelvic floor therapy.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of posterior tibial nerve stimulation have not been met. Therefore, we decided that 
the Plan does not have to pre-approve posterior tibial nerve stimulation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that the requested item is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested item is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. 
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (E0265).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics (L3000) provided on June 8, 2022. 
 
You asked the Plan to pay for foot orthotics. You say that the requested items are a medical necessity for you. 
The Plan denied your request. The Plan says these items are 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 June 
8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for COVID-19 at home test kits (8 boxes/16 tests) provided on 
February 9, 2022. 
 
You asked the Plan to pay for COVID-19 at home test kits. You say that you received an underpayment for 
COVID-19 at home test kits. The Plan denied your request. The Plan says the payment for the COVID-19 at 
home test kits is correct. 
 
The Plan must follow Medicare rules. Medicare rules say that starting April 4, 2022, over-the-counter (OTC) 
COVID-19 tests are covered by Original Medicare, so Medicare Advantage plans are not responsible for 
reimbursement of these test.  
 
We looked at the file and Medicare rules. Based on this information, since you purchased 16 individual tests in 
a calendar month, you will only be reimbursed for 8 individual tests and Medicare does not cover any tests 
above 8. Therefore, we decided that the Plan does not have to pay for COVID-19 at home test kits (8 boxes/16 
tests) provided on February 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral exam (D0150) provided on August 4, 
2022. 
 
You asked the Plan to pay for the dental service. You say that the dental service should be covered. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service May 18, 2021. Therefore, 
we decided that the Plan does not have to pay for a comprehensive oral exam (D0150) provided on August 4, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray provided on June 20, 2022. 
 
You asked the Plan to pay for an x-ray. You say that this was medically necessary and should be covered. 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).there was no preauthorization by a primary care provider (this is different than a referral) for an out-of-network (OON) provider or facility, and this was not an emergency. Therefore, we 
decided that the Plan does not have to pay for an x-ray provided on June 20, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70480 billed for date of service July 16, 
2022. 
 
You asked the Plan to pay for procedure code 70480. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70480 is bundled into payment for 
code 70450. 
 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 70480 
is a column II code to column I code 70450. 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 70480 billed for date of service July 16, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99072 billed for date of service May 13, 
2022. 
 
You asked the Plan to pay for procedure code 99072. You say that you were not aware that there was a 
problem with the patient's insurance at the time of the services. The Plan denied your request. The Plan says 
procedure code 99072 is considered bundled and 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 procedure code.  
We find that procedure code 99072 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99072 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99072 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99072 billed for date of service May 13, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 71045 billed for date of service November 18, 2021. 
 
You asked the Plan to pay for code 71045. You say that this claim was denied as a duplicate in error. The Plan 
denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly 
denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on December 17, 2021. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for code 71045 have not been met. Therefore, 
we decided that the Plan does not have to pay for code 71045 billed for date of service November 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 77063 billed for date of service July 26, 2021. 
 
You asked the Plan to pay for code 77063. You say that the patient had multiple exams on this date of service. 
The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was 
correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on June 27, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for code 77063 have not been met. Therefore, 
we decided that the Plan does not have to pay for code 77063 billed for date of service July 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure is medically reasonable 
and necessary. The Plan denied your request. The Plan says the requested procedure is considered 
experimental/investigational. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental. More research is needed before coverage can 
be approved 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 the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Cala Trio upper limb peripheral nerve stimulator 
device. 
 
You asked the Plan to pre-approve the Cala Trio device. You say that this is necessary for the enrollee's 
condition. The Plan denied your request. The Plan says this is not covered for the enrollee's medical condition. 
 
The Plan must follow Medicare rules. Medicare rules say that where electric nerve stimulation is employed to 
treat motor function disorders, no reimbursement may be made for the stimulator or for the services related to 
its implantation since this treatment cannot be considered reasonable and necessary. 
 
We looked at the file and Medicare rules. In this case, the nerve stimulator is being prescribed for the enrollees 
motor function disorder which is not a covered indication. Based on this information, we decided that Medicare 
rules for coverage of the Cala Trio device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Cala Trio upper limb peripheral nerve stimulator device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computerized tomography (CT) scan (D0367) and 
implants (D6010) for tooth #4, #5, #12, #13, #19, #21, and #30. 
 
You asked the Plan to pre-approve the dental services. You say that the dental services are medically necessary. 
The Plan denied your request. The Plan says the records show the enrollee received a partial denture to replace 
their teeth; therefore, the denial of authorization for the implants is correct. Also, the denial for the CT scan is 
correct, because CT scans are not covered by the Plan's 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. The Plan covers the dental 
services when the services are medically necessary and reasonable.  
 
  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 dental services. Our reviewer says 
that the implants are not medically necessary. Our physician reviewer found that documentation that other 
prostheses have not been placed in the past 60 months is required before implants can be approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a computerized tomography (CT) scan (D0367) and implants (D6010) for tooth #4, #5, 
#12, #13, #19, #21, and #30.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 18, 2022. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary and should be covered. 
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).there was no preauthorization by a primary care provider (this is different than a referral) for an out-of-network (OON) provider or facility, and this was not an emergency. Therefore, the 
decision is upheld. Therefore, we decided that the Plan does not have to pay for an office visit provided on 
August 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay provided on July 29, 
2022, to August 01, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you shouldnt have to pay 
for this. 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 $290 
copayment for Inpatient hospital care. 
 
You have been asked to pay a $290 copayment for inpatient hospital stay. This item/service falls 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.You have been asked to pay a $870 ($290 x 3 days) copayment for inpatient hospital stay. 
Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital stay provided 
on July 29, 2022, to August 01, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction of tooth #5, 7, 12, 22, 23, 24, 25, 26, and 28 
(D7140), an immediate maxillary denture (D5130), and an immediate mandibular denture (D5140) provided on 
June 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial for dental services. 
The Plan denied your request. The Plan says extractions (D7140), an immediate maxillary denture (D5130), 
and an immediate mandibular denture (D5140) are not covered by 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 the 
extraction of tooth #5, 7, 12, 22, 23, 24, 25, 26, and 28 (D7140), an immediate maxillary denture (D5130), and 
an immediate mandibular denture (D5140) provided on June 23, 2022.