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

 
We decided that the Plan does not have to pre-approve a repeat sacroiliac joint (SIJ) injection. 
 You asked the Plan to pre-approve the requested services. You say that the enrollee has persistent pain. The 
Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that sacroiliac joint injections are only covered under 
certain medical indications.  
 
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 requested services. Our physician 
reviewer found that the enrollee has chronic low back pain and Sacroiliitis. On October 17, 2022, the enrollee 
underwent bilateral SI joint injections and achieved 50% pain relief for 10 days. A repeat therapeutic SI joint 
injection is indicated when it produced at least consistent 50% pain relief or at least 50% consistent 
improvement in the ability to perform previously painful movements and activities of daily living for at least 
three months from the proximate therapeutic SIJI procedure. This was not achieved and therefore, the request is 
deemed not 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a repeat sacroiliac joint (SIJ) injection.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93042 billed for date of service September 
11, 2022. 
 
You asked the Plan to pay for procedure code 93042. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 93042 is bundled into payment for code 
99291. 
 
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 93042 is a column II code to column I code 99291 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 93042 billed for date of service September 11, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Oxtellar XR tablets. 
 
You asked the Plan to pre-approve Oxtellar XR. You say that the medication is medically necessary. The Plan 
denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
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 Oxtellar XR tablets.   
Benefits for Oxtellar XR 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prefabricated post and core (D2954), a crown 
(D2750), and a resin-based composite (D2391). 
 
You asked the Plan to pre-approve the dental services. You say that these services 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 on June 4, 2022, and July 
23, 2022. Therefore, we decided that the Plan does not have to pre-approve a prefabricated post and core 
(D2954), a crown (D2750), and a resin-based composite (D2391).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intraosseous ablation of the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the Intracept procedure is medically 
necessary. The Plan denied your request. The Plan says the Intracept procedure 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 the Intracept procedure. Our reviewer 
says that the requested Intracept procedure is not considered medically reasonable and necessary. Our 
physician reviewer found the literature indicates that the Intracept procedure targets the basivertebral nerve for 
the relief of chronic vertebrogenic low back pain.  Medicare guidelines consider this type of system unproven 
and not medically necessary.  Large well-designed studies in the peer review scientific literature comparing 
stand-alone use of Intracept device to established surgical decompression are needed. Published studies do not demonstrate any long-term health outcome advantage with the use of Intracept as an alternative to standard 
surgical treatment. In this case, the review has determined that the requested Intracept procedure is not 
medically reasonable or necessary for the enrollee. 
 
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 intraosseous ablation of the Intracept procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue additional reimbursement for the health club membership 
(S9970) purchased on October 1, 2022. 
 
You asked the Plan to issue additional reimbursement for this service. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says you are not 
eligible for additional reimbursement of the membership purchased. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
  
 
The Plans rules for coverage of gym benefits have not been met because you are not eligible for additional 
reimbursement. Specifically, you enrolled in the plan on October 1, 2022. The monthly payment for your  
portion of the gym membership purchased was $10.80. The Plan issued reimbursement to you in the amount of 
$32.40 ($10.80 x 3) for the months of October, November, and December of the 2022 calendar year. Therefore, 
the Plan issued reimbursement for this membership appropriately. Therefore, we decided that the Plan does not 
have to issue additional reimbursement for the health club membership (S9970) purchased on October 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex interspinous stabilization device. 
 
You asked the Plan to pre-approve the requested services. You say that it is difficult for the enrollee to stand or 
walk for an extended period of time. The Plan denied your request. The Plan says there are not enough studies 
to show it is safe and effective. 
 
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 requested services. Our physician 
reviewer found Our physician reviewer found that the Vertiflex device is considered experimental. More 
research is needed to show its safety and efficacy. Therefore, the request is 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Vertiflex interspinous stabilization device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of residual tooth roots (D7250) and bone 
replacement graft (D7953). 
 
You asked the Plan to pre-approve removal of residual tooth roots and bone replacement graft. You say that 
this should be covered. The Plan denied your request. The Plan says this is not a covered service. 
 
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 
removal of residual tooth roots (D7250) and bone replacement graft (D7953).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a retainer crown - porcelain fused to high noble metal 
(D6750 x2), and pontic - porcelain fused to high noble metal (D6240 x1) provided on March 13, 2023. 
 
You asked the Plan to pay for the dental services represented by codes D6750 and D6240. You say that you 
have the enhanced dental and vision package and your bridge was rejected. You also say that nowhere on the 
Plan's documentation does it show that bridge replacements are not covered. The Plan denied your request. The 
Plan says codes D6750 and D6240 are not shown as covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a retainer crown - 
porcelain fused to high noble metal (D6750 x2), and pontic - porcelain fused to high noble metal (D6240 x1) 
provided on March 13, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network emergency room (ER) visit 
provided on January 23, 2023. 
 
You asked the Plan to waive the copayment for an in-network emergency room (ER) visit. You say that you 
thought this was a follow up to a previous ER visit, not a new ER visit. 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 $95 
copayment for emergency care. 
 
You have been asked to pay a $95 copayment for an in-network emergency room (ER) visit. This item/service 
falls within the emergency 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 
an in-network emergency room (ER) visit provided on January 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the hearing aids (V5261) purchased on September 30, 
2022, from an out-of-network (OON) provider. 
 
You asked the Plan to pay more for the hearing aids. You say that it was far cheaper for you to purchase these 
hearing aids from the OON provider, and you would like additional reimbursement. The Plan denied your 
request. The Plan says 25% of the Maximum Allowed Fee ($1,000) is $250.00, producing the 25% 
coinsurance. The Plan also says that 250.00 plus 599.99 (the amount over $1,000) produces your responsibility 
of $849.99. 
 
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.  
 
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 aids have not been met. The contract clearly states that you are responsible for a 25% 
coinsurance plus any amount over $1,000 for hearing aids every three years. Therefore, we decided that the 
Plan does not have to pay more for the hearing aids (V5261) purchased on September 30, 2022, from an out-of-
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on January 03, 
2023. 
 
You asked the Plan to waive the copayment for an office visit. 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 a $15 
copayment for podiatry services. 
 
You have been asked to pay a $15 copayment for an office visit. This item/service falls within the podiatry 
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 an office visit provided on 
January 03, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient hospital visit provided on 
October 25, 2022. 
 
You asked the Plan to waive the copayment for an outpatient hospital visit. 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 a $325 
copayment for Outpatient hospital services. 
 
You have been asked to pay a $325 copayment for an outpatient hospital visit. This item/service falls within the 
Outpatient hospital 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 an 
outpatient hospital visit provided on October 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network nail debridement provided 
on November 03, 2022, to December 13, 2022. 
 
You asked the Plan to waive the copayment for an in-network nail debridement. You say that you were not 
aware that these nail scrapings were considered a procedure. This is a large copayment for this visit. 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 $295 
copayment for Medicare-covered outpatient hospital facility visit. 
 
You have been asked to pay a $295 copayment for an in-network nail debridement. This item/service falls 
within the Medicare-covered outpatient hospital facility visit 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 had a copayment of $295 per visit. You had 5 
visits, resulting in a total copayment amount of $1,475 ($295 x 5 = $1,475). Therefore, we decided that the 
Plan does not have to waive the copayment for an in-network nail debridement provided on November 03, 
2022, to December 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing - four or more teeth 
per quadrant (D4341). 
 
You asked the Plan to pre-approve the periodontal scaling and root planing. The Plan denied your request. The 
Plan says this service is not covered under the benefit package. 
 
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 
periodontal scaling and root planing - four or more teeth per quadrant (D4341).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the ambulance transportations provided 
from December 20, 2022, to December 30, 2022, the inpatient hospital stay provided from December 28, 2022, 
to December 30, 2022, and the emergency room services provided on January 2, 2023. 
 You asked the Plan to waive the copayments for the ambulance transportation, the inpatient hospital stay, and 
the emergency room services You say that you disagree with the charges. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $260 copayment for each Medicarecovered oneway transportation via ground. The enrollees 
contract with the Plan also clearly says that enrollees must pay a $300 copayment per day, for days 1 to 5 and 
$0 copayment per day, for days 6 to 90 for each medically necessary covered inpatient stay. The enrollees 
contract with the Plan also clearly says that enrollees must pay a $95 copay for emergency care. 
 
The enrollee has been asked to pay a $260 copayment for each ambulance transportation provided on 
December 20, 2022, December 28, 2022, and December 30, 2022. You have been asked to pay a total of $780 
for the ambulance transportation ($260 copayment x 3 trips = $780). These items/services fall within the 
ambulance services benefit category. The record shows the Plan reprocessed this claim and reduced the 
copayment for the inpatient hospital stay. You have also been asked to pay a $300 copayment per day, for days 
1 to 2 of the inpatient hospital stay. You have been asked to pay a total of $600 for the inpatient hospital stay 
($300 copayment x 2 days = $600). You have not been charged for any additional days. This item/service falls 
within the inpatient hospital care benefit category. You have also been asked to pay a $95 copayment for the 
emergency room visit provided on January 2, 2023. This item/service falls within the emergency care benefit 
category. 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 copayments for the ambulance transportations 
provided from December 20, 2022, to December 30, 2022, the inpatient hospital stay provided from December 
28, 2022, to December 30, 2022, and the emergency room services provided on January 2, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services on November 1, 2021, to November 30, 
2021. 
 
You asked the Plan to pay for home health services. You say that you would like to request reconsideration of 
the denied claim. The Plan denied your request. The Plan says the provider has 12 months or 1 calendar year 
from the date the services were furnished to submit a claim. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for home health services was not filed until December 22, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for home health services on November 1, 2021, to November 30, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - periapical first radiographic image (D0220) and 
intraoral - periapical each additional radiographic image (D0230) provided on February 15, 2023. 
 
You asked the Plan to pay for dental benefits. You say that you told the provider to only perform services that 
were covered by your insurance; therefore, you should not be liable for the billed charges. The Plan denied 
your request. The Plan says these services are not covered under 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. Intraoral - periapical first 
radiographic image (D0220) and intraoral - periapical each additional radiographic image (D0230) are not 
covered under the Plans dental benefits. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D0220 and D0230 are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
intraoral - periapical first radiographic image (D0220) and intraoral - periapical each additional radiographic 
image (D0230) provided on February 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mandibular partial denture (D5226). 
 
You asked the Plan to pre-approve the dental services. You say that this 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 June 24, 2021. Therefore, 
we decided that the Plan does not have to pre-approve mandibular partial denture (D5226).