Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Therapeutic activities (97110 and 97530) provided from 
July 28, 2021, to August 16, 2021.  
You asked the Plan to pay for the Therapeutic activities. 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. 
 
The Plan must follow Medicare rules. Medicare rules say that the services of a PTA and an OTA shall not be 
billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet 
the qualifications of a therapist. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of physical therapy and occupational therapy have not been met. Specifically, the billing provider is a 
nurse practitioner, and not a licensed therapist. As such, PTA and OTA services cannot be paid incident to this 
provider's professional services. Therefore, we decided that the Plan does not have to pay for the Therapeutic 
activities (97110 and 97530) provided from July 28, 2021, to August 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve an office visit. You say that you were advised you can continue with your primary care provider. The Plan denied your request. The Plan says the provider is out-of-network and it was determined these services can be received in-network. We do not have evidence that you are unable to see a provider within the PCP network or that seeing a provider within the PCP network would not meet your needs.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigation (D4921 x 4), and take home drugs 
(D9630 x 2) provided from December 2, 2021, to December 7, 2021. 
 
You asked the Plan to pay for the gingival irrigation and take home drugs. You say that you simply wanted a 
bi-annual cleaning. You say that the dentist performed gingival irrigation instead. You say that you did not ask 
for a deep cleaning. You say that you were sent to this office by a plan representative. You also say that you 
feel the people at this dental office are thieves. The Plan denied your request. The Plan says ginigval irrigation 
and take home drugs are not listed as covered services. 
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 ginigval irrigation and take home 
drugs are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay 
for the gingival irrigation (D4921 x 4), and take home drugs (D9630 x 2) provided from December 2, 2021, to 
December 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the implant supported crown (D6065) provided on January 
20, 2021. 
 
You asked the Plan to pay for the dental service. You say that there was no other way to attach the crown than 
with an implant. The Plan denied your request. The Plan says crowns nor implants are listed as covered service. 
The Plan also says that the claim processed correctly. 
 
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 implant supported crown is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
implant supported crown (D6065) provided on January 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat elevation feature. 
 
You asked the Plan to pre-approve the requested service. The Plan denied your request. The Plan says the lift 
does not serve a primary medical purpose. 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
We looked at the file and the rules. The item at issue in this appeal does not serve a purpose that is primarily 
medical in nature. Therefore, we decided that the Plan does not have to pre-approve a seat elevation feature.
Appeal type: Surgery
Decision: Unfavorable

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

 
We decided that the Plan does not have to pay for the extraction, erupted tooth requiring removal of bone 
and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) provided 
November 30, 2021. 
 
You asked the Plan to pay for the surgical tooth extraction. You say that without this service you could have 
had a blood clot to your brain. The Plan denied your request. The Plan says this service is not covered under 
your dental or medical benefits. 
 
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 
extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of 
mucoperiosteal flap if indicated (D7210) provided November 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 7, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services provided by an OON provider. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network 
care. 
 
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 the laboratory services provided on December 7, 
2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endosteal implants (D6010) to be provided by a 
participating provider. 
 
You asked the Plan to pre-approve endosteal implants. You say that you are unable to chew and eat properly. 
The Plan denied your request. The Plan says D6010 is not a covered dental 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 pre-approve 
endosteal implants (D6010) to be provided by a participating provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the treatment of femoral fracture (27245) provided on 
September 14, 2020. 
 
You asked the Plan to pay for the treatment of femoral fracture (27245). You say that the operative report 
should be reviewed, and the assistant should be paid for her services. The Plan denied your request. The Plan 
says services of Surgical Technicians and RN First Assists (RNFA) are not eligible for separate reimbursement. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
  In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for the treatment of femoral fracture 
(27245) provided on September 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam CT image (D0380), and periradicular surgery 
(D3428) provided on December 21, 2021. 
 
You asked the Plan to pay for the cone beam CT and periradicular surgery. You say that the dental procedure 
was recommended by your provider. The Plan denied your request. The Plan says cone beam CT and 
periradicular surgery are not listed as covered services. 
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 cone beam CT and periradicular 
surgery are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for the cone beam CT image (D0380), and periradicular surgery (D3428) provided on December 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete set of radiographic images (D0210), and a 
comprehensive oral evaluation (D0150) provided by a participating provider on February 8, 2022. 
 
You asked the Plan to pay for a complete set of radiographic images and a comprehensive oral evaluation. You 
say that you would like the Plan to pay for this. The Plan denied your request. The Plan says the benefit limit 
for the rendered dental services have already been met and exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a complete set 
of radiographic images once every five years and a comprehensive oral evaluation once every three years. 
 
We looked at the file and Medicare rules. Evidence was provided to show that these services were provided on 
November4, 2021. Based on this information, we decided that the Plan's rules for coverage of a complete set of 
radiographic images and a comprehensive oral evaluation have not been met. Therefore, we decided that the 
Plan does not have to pay for a complete set of radiographic images (D0210), and a comprehensive oral 
evaluation (D0150) provided by a participating provider on February 8, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room (ER) visit provided on 
May 1, 2021, and July 20, 2021. 
 
You asked the Plan to waive the copayment for the ER visits. You say that the services should be covered as 
you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied correctly 
based on the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $90 copayment for Emergency care.  
 
 
  The enrollee has been asked to pay a $180 copayment for two ER visits ($90 x 2 = $180). This means that the 
enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a 
contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for emergency room (ER) visit provided on May 1, 2021, and July 20, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the finger joint repair and reconstruction (26548) provided 
on April 28, 2021. 
 
You asked the Plan to pay for the finger joint repair and reconstruction (26548). You say that pertinent 
documentation is enclosed for review and proper reimbursement for the providers service should be provided. 
The Plan denied your request. The Plan says procedure codes 25447, 26480, 26862 and 26863 were approved 
and procedure code 26548 is not supported by the medical records submitted. 
 
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 26548 is repair and reconstruction, finger, volar plate, 
interphalangeal joint. 
  We asked our coder 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 finger joint repair and reconstruction (26548). Our 
reviewer says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our 
reviewer found the operative report does not describe dissection of interphalangeal joint, and plate of the joint 
sutured to the proximal and distal bones to stabilize the joint. In this case, CPT code 26548 cannot be verified 
as performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the finger joint repair and reconstruction (26548) have not been met. Therefore, 
we decided that the Plan does not have to pay for the finger joint repair and reconstruction (26548) provided on 
April 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-precision abutment (D6191). 
 
You asked the Plan to pre-approve a semi-precision abutment. You say that this service is medically necessary. 
The Plan denied your request. The Plan says this dental service is not among those 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 a 
semi-precision abutment (D6191).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for photopheresis services (36522) provided 
from October 26, 2021, to December 28, 2021. 
 
You asked the Plan to waive the copayment the photopheresis services. You say that the services should be 
covered as you disagree with the charges and how the service is coded. The Plan denied your request. The Plan 
says the cost-sharing applied correctly based on the services provided. 
 
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 $325 
copayment for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 You have been asked to pay a $325 copayment for the photopheresis services. Photopheresis services fall 
within the Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers 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 photopheresis services 
(36522) provided from October 26, 2021, to December 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
September 21, 2021. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 
 
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 $35 
copayment for Physician/Practitioner services, including doctors office visits.  
 
 You have been asked to pay a $35 copayment for the specialist office visit. 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 a specialist office visit provided on September 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for problem focused limited oral exam (D0140) provided 
December 21, 2021 to January 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told by member services that you 
could submit an out of network claim since there were no in-network providers in your area. You were not told 
that an authorization would be required at this time. The Plan denied your request. The Plan says the claim was 
reprocessed and paid as a one-time exception except for D0140 which is not covered under the Plan benefits. 
 
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 problem 
focused limited oral exam (D0140) provided December 21, 2021 to January 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that this device is medically reasonable and 
necessary. The Plan denied your request. The Plan says the criteria for coverage for this device have not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
therapeutic continuous glucose monitor (CGM).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan 
(74177) provided on January 24, 2022. 
 
You asked the Plan to waive the copayment for the CT scan. You say that the services should be covered as 
you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied correctly 
based on the services provided. 
 
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 $350 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 You have been asked to pay a $343.07 copayment for a CT scan, which is less than the standard $350. CT 
scans fall within the Outpatient diagnostic tests and therapeutic services and supplies 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 computed tomography (CT) scan (74177) provided on 
January 24, 2022.