Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram (EKG) provided on December 28, 
2022. 
 
You asked the Plan to pay for the electrocardiogram (EKG). You say that the enrollee was in a nursing home 
and it was assumed that the admission authorization covered these services. 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). Therefore, we decided that the Plan does not have to pay for the electrocardiogram 
(EKG) provided on December 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing code 0012M billed for date of service November 
8, 2022. 
 You asked the Plan to pay for the billed services. You say that the testing was medically necessary. The Plan 
denied your request. The Plan says the test is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. 
 
We find that the CxBladder test, identified by CPT code 0012M is not a covered test. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for lab testing code 0012M billed for date of service November 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete denture-maxillary (D5110). 
 
You asked the Plan to pre-approve the dental service. You say that your dentures were broken in an accident 
and wearing your older pair is causing severe pain. 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 January 12, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a complete denture-maxillary (D5110).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiologic examination provided on January 17, 2023. 
 
You asked the Plan to pay for radiologic examination. You say that the services were medically necessary. 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). Therefore, we decided that the Plan does not have to pay for radiologic examination 
provided on January 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder test billed for date of service December 8, 
2022.  
 
You asked the Plan to pay for the billed services. You say that the evidence supporting the test is well 
established. The Plan denied your request. The Plan says the test is not covered. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The rules say that the test at issue is non-covered. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for the CxBladder test billed for date of service December 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the continuous positive airway pressure 
(CPAP) equipment provided on January 19, 2023. 
 
You asked the Plan to waive the coinsurance for the continuous positive airway pressure (CPAP) equipment. 
You say that you are being charged over the 20% coinsurance amount. 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 50% 
coinsurance for out-of-network durable medical equipment.  
You have been asked to pay 50% coinsurance for the continuous positive airway pressure (CPAP) equipment. 
This item/service falls within the out-of-network durable medical equipment 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. The records show the provider is out-
of-network, and the 50% out-of-network coinsurance was applied correctly. The total you owe is $20.02 
($40.04 allowed amount x 50% coinsurance = $20.02). Therefore, we decided that the Plan does not have to 
waive the coinsurance for the continuous positive airway pressure (CPAP) equipment provided on January 19, 
2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3. 
 
You asked the Plan to pre-approve Gelsyn-3. You say that the service is medically necessary. The Plan denied 
your request. The Plan says you have not tried and failed preferred agents Orthovisc or Synvisc/Synvisc One 
which is Medicare part B step therapy requirement. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of Gelsyn-3 have been met. There were 
no medical records submitted to show whether the Plan's step therapy criteria have been met. Therefore, we 
decided that the Plan does not have to pre-approve Gelsyn-3.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is a high risk to return to a 
short-term acute care hospital if they go to a skilled nursing facility. You say that the enrollee would have the 
maximum benefit at a LTACH. The Plan denied your request. The Plan says an LTACH admission is not 
medically necessary, and the enrollee's needs can be met in their current hospital setting.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
  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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where the enrollee is currently receiving care. The health plan has approved ongoing care in 
the current acute care setting. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve surgical placement of implant body, endosteal (D6010), 
prefabricated abutment, includes modification and placement (D6056), implant supported porcelain/ceramic 
crown (D6065), and bone replacement graft for ridge preservation, per site (D7953) for tooth #18. 
 
You asked the Plan to pre-approve surgical placement of implant body, prefabricated abutment, implant 
support crown and bone replacement graft. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says that the dentist must tell us what the plan is for all missing teeth and teeth 
that cannot be fixed. Based on your records your dentist sent in, they did not tell us about the plan for all teeth. 
Without this plan being given to us the long-term outlook of your oral health is not established as having a 
good outlook with this 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. The Plan covers surgical 
placement of implant body, prefabricated abutment, implant support crown and bone replacement graft 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 surgical placement of implant body, 
prefabricated abutment, implant support crown and bone replacement graft. Our reviewer says that the service 
is not medically necessary. Our physician reviewer found the documentation provided meets the criteria for 
coverage of medically reasonable and necessary for D6010, D6056 and D7953. 
 
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 surgical placement of implant body, prefabricated abutment, implant support 
crown and bone replacement graft have been met. Therefore, we decided that the Plan has to pre-approve 
surgical placement of implant body, endosteal (D6010), prefabricated abutment, includes modification and 
placement (D6056), implant supported porcelain/ceramic crown (D6065), and bone replacement graft for ridge 
preservation, per site (D7953) for tooth #18.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675) provided on 
September 8, 2022, through September 27, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the item was medically necessary. 
The Plan denied your request. The Plan says a PCD is not covered by Medicare to prevent deep vein 
thrombosis during and/or following surgery.  
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for the pneumatic compression device (E0675) provided on September 8, 2022, through September 27, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bed assembly, gel foam mattress, bedside table, and a tub 
transfer bench, purchased from a non-certified provider on January 3, 2023, through January 16, 2023. 
 
You asked the Plan to pay for the bed assembly, gel foam mattress, bedside table, and a tub transfer bench. You 
say that the items were medically necessary and should be covered. The Plan denied your request. The Plan 
says you purchased these items through a provider that is not certified with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the bed assembly, gel foam mattress, 
bedside table, and a tub transfer bench, purchased from a non-certified provider on January 3, 2023, through 
January 16, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Interstim device (64561). 
 
You asked the Plan to pre-approve an Interstim device. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the service 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 an Interstim device. Our reviewer says 
that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no documented failure or intolerance to conventional 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 an Interstim device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an Interstim device (64561).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have  to pay for intravenous moderate (conscious) sedation/analgesia- first 
15 minutes (D9239), each subsequent 15 minute increment (D9243), osseous, osteoperiosteal, or cartilage graft 
of the mandible or maxilla - autogenous or nonautogenous, by report (D7950), surgical removal of implant 
body (D6100), and unspecified preventive procedure, by report (D1999) provided on October 20, 2022. 
 
You asked the Plan  to pay for the dental services represented by codes D9239, D9243, D7950, D6100 and 
D1999. You say that the services were not dental but medical due to cardiac issues. The Plan denied your 
request. The Plan says you received services from a provider who chose not to received Medicare funds. 
 The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have  to pay for 
intravenous moderate (conscious) sedation/analgesia- first 15 minutes (D9239), each subsequent 15 minute 
increment (D9243), osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla - autogenous or 
nonautogenous, by report (D7950), surgical removal of implant body (D6100), and unspecified preventive 
procedure, by report (D1999) provided on October 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the VIA Disc allograft intervertebral disc augmentation 
procedure. 
 
You asked the Plan to pre-approve the VIA Disc allograft intervertebral disc augmentation procedure. You say 
that the service is medically necessary. The Plan denied your request. The Plan says this procedure is 
considered experimental. 
 
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 VIA Disc allograft intervertebral 
disc augmentation procedure. Our reviewer says that the requested services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found this procedure is considered experimental. 
 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 VIA Disc allograft intervertebral disc augmentation procedure have not 
been met. Therefore, we decided that the Plan does not have to pre-approve the VIA Disc allograft 
intervertebral disc augmentation procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on February 07, 
2023. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you do not think you should be 
responsible for this copayment. 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 each specialist visit for Medicare-covered benefits. 
 
You have been asked to pay a $15 copayment for a specialist visit. This item/service falls within the each 
specialist visit for Medicare-covered benefits 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 a specialist visit provided on February 07, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the intraoral-periapical first radiographic image (D0220) and the  
re-cement or re-bond of a crown (D2920) provided on March 27, 2023. 
 
You asked the Plan to pay for these dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says that the services are not payable as they 
were rendered by an out-of-network dental provider.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has stated that the dental services in this case are not 
payable as they were rendered by an out-of-network provider. However, the Plan has not provided the correct 
Evidence of Coverage contract for the year in which the services were rendered. The Plan has not substantiated 
their denial; therefore, we must find in your favor. Therefore, we decided that the Plan has to pay for the 
intraoral-periapical first radiographic image (D0220) and the re-cement or re-bond of a crown (D2920) 
provided on March 27, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: 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 it is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet the requirements for approval. 
 
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 the complexity of the enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for respiratory failure. Medical problems are stable. There are no complex nursing or 
rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
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.