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

 
We decided that the Plan does not have to reinstate the OTC benefit. 
 
You asked the Plan to reinstate the OTC benefit. You say that you want to extend the 2021 over-the-counter 
drug allowance. The Plan denied your request. The Plan says there is a $25 allowance per quarter, and quarterly 
allowances cannot be carried over to another quarter. 
 
Though the Plan offers OTC benefits in excess of Medicare coverage, the OTC allowance cannot be carried 
over to another quarter. Therefore, we decided that the Plan does not have to reinstate OTC benefits.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 13, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams 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. 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 70450 billed for date of service May 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injections provided on August 5, 2021. 
 
You asked the Plan to waive the coinsurance for injections. You say that you cannot afford this bill. The Plan 
denied your request. The Plan says the coinsurance applied is correct. 
 
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 20% 
coinsurance for Medicare covered Part B chemotherapy drugs and other Part B drugs.  
 
You have been asked to pay $312.81 which is 20% of the allowed amount for the injections. Injections fall 
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 injections provided on August 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the chest Computed Tomography Angiography (CTA). 
 
You asked the Plan to pre-approve the CTA. You say that you would like reconsideration because the 
requested CTA is medically necessary. The Plan denied your request. The Plan says the documentation does 
not show that the enrollee is having heart problems and there is no information as to how the results of a chest 
CTA will change the enrollee's treatment plan. 
 
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 CTA. Our reviewer says that the 
enrollee has no apparent cardiac signs or symptoms. Clinical guidelines for the use of chest CTA have not been 
met based on review of the submitted clinical documentation. Our physician reviewer found at this time chest 
CTA would not be considered medically reasonable and necessary in this patient's clinical management. 
 
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 CTA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the chest Computed Tomography Angiography (CTA).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on April 6, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
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 office visit provided on April 6, 2022, by an out-
of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you want the Plan to reconsider the admission to a 
SNF. The Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have documented skilled nursing needs and is doing well 
with the current therapy. There is no advantage in transferring the enrollee to a SNF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits (99212, 99213) provided from April 6, 2022, 
to April 27, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the physician services. You say that before you renewed your contract for 2022, 
you confirmed with the plan that your providers were all still in-network. You say that the provider was in the 
process of renewing their contract with your plan on the date of service in this case. You also say that you 
should not be responsible for this bill. The Plan denied your request. The Plan says there was no documentation 
to support that the services were urgent or emergent. The Plan also says there are in-network providers 
available. 
 
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. 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 the office visits (99212, 99213) provided from 
April 6, 2022, to April 27, 2022, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy (PT) services. 
 
You asked the Plan to pre-approve PT services. You say that you have lower back, neck, and hand pain. You 
also say that you were advised there was no progress after one evaluation and two visits, and would like 
additional PT to be approved. The Plan denied your request. The Plan says an order and/or clinical information 
was unable to be obtained from your primary care physician or neurologist by the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 
 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 PT services. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the additional requested therapy generally is not accepted as specific 
and effective therapy for your condition beyond what was approved by the health plan without additional 
information. You have had prior therapy of only two sessions, and the documentation does not reveal that you 
require the unique skills of a professional therapist to safely and effectively provide treatment, that the services 
can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist 
without additional information. Our reviewer also found that at this time the requested services are not part of a 
maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not required 
to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further 
deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PT services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve physical therapy (PT) services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on June 
14, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you did not request 
the ambulance. 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 $317 
copayment for each one-way ambulance transport.  
 
You have been asked to pay a $317 copayment for the ambulance transportation. The ambulance transportation 
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 copayment for 
ambulance transportation provided on June 14, 2022.
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 the enrollee needs IRF care. The Plan denied your 
request. The Plan says the records do not show the need for the intensity of an IRF or full-time access to a 
doctor or skilled rehabilitation nurse. 
 
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 the enrollees nursing, medical and rehabilitation needs does not require an IRF stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, at an intensive 
rehabilitation therapy program. The enrollee continues to have a need for skilled therapy with ongoing safety 
concerns and a potential for functional improvement however, the documentation doesnt support that the 
criteria for admission to an IRF are met. There is no indication that the enrollee would require skilled 
rehabilitation in an IRF, participating in rehabilitation services 15 hours a week, under the supervision of a 
physician with at least 3 visits weekly to regain or maintain functional status. The enrollee can receive further 
services at a lower level of care. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the cervical spine. 
 
You asked the Plan to pre-approve a CT of the cervical spine. You say that this test was ordered so the doctor 
can see every angle and try to make sure your condition does not worsen, and they can try to get you some 
relief. The Plan denied your request. The Plan says there is no medical need for repeat imaging. 
 
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 a CT of the cervical spine. Our 
reviewer says that a CT of the cervical spine is not reasonable and necessary. Our physician reviewer found a 
CT of the cervical spine was already performed. There is no documentation of clinical changes or concern for 
clinical changes. Our reviewer also found that a repeat CT is not needed 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 CT of the cervical spine have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a computed tomography (CT) scan of the cervical spine.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heart stress test. 
 
You asked the Plan to pre-approve a heart stress test. The Plan denied your request. The Plan says you have 
some risk factors and symptoms suggestive of coronary artery disease (CAD). The Plan also says that a heart 
tracing report was not provided, and a standard (exercise stress test) heart test was not attempted. 
 
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 a heart stress test. Our reviewer says 
that a heart stress test is not considered medically reasonable and necessary in this case. Our physician reviewer 
found based on your history, an arrhythmia is highest in the differential suggesting a need for a full workup for 
this condition including an electrocardiogram (ECG), event monitor, and stress test. A heart tracing report was 
not provided in the notes suggesting this has not been done. Our reviewer found that a stress test is part of this 
workup, however, there was no contraindication for you doing a standard (exercise) stress test. Our physician 
reviewer also found that this request for myocardial perfusion stress test will be considered not medically 
necessary 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 heart stress test have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a heart stress test.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from April 25, 
2022, to April 29, 2022. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you had surgery and 
there were complications. You say that these circumstances were not expected. The Plan denied your request. 
The Plan says the copayment applied was correct. 
 
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 $295 
copayment for days 1 to 4 for Medicare-covered hospital care each time you are admitted. $0 copayment for 
additional Medicare-covered days.  
 
You have been asked to pay a total of $1,180 for an inpatient hospital stay (4 days x $295 copayment = 
$1,180). An inpatient hospital stay falls within the Inpatient Hospital Care benefit category. Inpatient hospital 
care starts the day you are formally admitted to the hospital with a doctors order. The day before you are 
discharged is your last inpatient day.  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 inpatient hospital stay from April 25, 2022, to April 29, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided by a network 
provider on May 20, 2022. 
 
You asked the Plan to pay for the limited oral evaluation (D0140). You say that the limited oral evaluation 
should be covered because emergency visits should be covered. The Plan denied your request. The Plan says 
the service was 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, 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 
limited oral evaluation (D0140) provided by a network provider on May 20, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial comprehensive preventive medicine evaluation and 
management (99387) provided on May 12, 2022. 
 
You asked the Plan to pay for the initial comprehensive preventive medicine evaluation and management. The 
Plan denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a preventive medicine service (current 
procedural terminology codes 99381 to 99397) is a non-covered service.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the initial comprehensive preventive medicine evaluation and management have not been met. 
Therefore, we decided that the Plan does not have to pay for the initial comprehensive preventive medicine 
evaluation and management (99387) provided on May 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 0037U for date of service December 13, 2021. 
 
You asked the Plan to pay for code 0037U. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 0037U is not supported in the medical record. Specifically, the documentation shows 
that the specimen was collected on November 19, 2021. This means the claim is not payable as billed. Based 
on this information, we decided that Medicare rules for coverage of code 0037U have not been met. Therefore, 
we decided that the Plan does not have to pay for code 0037U for date of service December 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint radiofrequency ablation procedure 
(64625). 
 
You asked the Plan to pre-approve the procedure. You say that this procedure is medically necessary. The Plan 
denied your request. The Plan says the requested procedure is experimental and non-covered. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found radiofrequency ablation for denervation, whether performed using traditional, cooled, or pulsed 
radiofrequency, is considered investigational and therefore, not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sacroiliac joint radiofrequency ablation procedure (64625).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of torus mandibularis (D7473) 
 
You asked the Plan to pre-approve the dental service. You say that you need this procedure done so you can 
receive your dentures. The Plan denied your request. The Plan says he denial of authorization for this service is 
correct, because the removal of torus mandibularis is not covered by 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. Therefore, we decided that the Plan does not have to pre-approve the 
removal of torus mandibularis (D7473)