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

 
We decided that the Plan does not have to pre-approve percutaneous coronary intervention (PCI) services 
represented by codes 92933, 92924, 92943, 92937, 92928, and 92920.  
 
You asked the Plan to pre-approve PCI services. You say that the records provided support the need for the 
services being requested.  The Plan denied your request. The Plan says they did not receive a cardiac 
catheterization showing the severity of stenosis. The Plan says that the clinical information received does not 
support that the services being requested are 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 PCI services. Our reviewer says that 
PCI services are not considered medically reasonable and necessary in this case. Our physician reviewer found 
records show no significant coronary artery disease on cardiac catheterization.  As a result, at this time PCI would not be considered medically appropriate and necessary in this enrollee'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 PCI services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous coronary intervention (PCI) services represented by codes 92933, 92924, 
92943, 92937, 92928, and 92920.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on May 4, 2023. 
 
You asked the Plan to pay for the dental services. You say that this was medically necessary. The Plan denied 
your request. The Plan says the dental services were received from an out-of-network provider and are not 
covered by your supplemental benefits.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for dental services provided on May 4, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from June 16, 2022, to July 
11, 2022. 
 
You asked the Plan to pay for inpatient care. You say that these services were medically necessary. The Plan 
denied your request. The Plan says procedure code 02BL0ZZ is not covered; therefore, the claim cannot be 
allowed or priced. 
 
The Plan follows Medicare rules. Medicare rules state that some operating room procedure which are not 
covered will result in the claim being returned to the provider. 
 
We asked our coding 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 pay for inpatient care. Our reviewer says that this 
inpatient claim does not meet criteria for payment. Our physician reviewer found per Medicare, procedure 
02BL0ZZ excision of left ventricle, open approach is always identified as a non-covered procedure.  
We looked at this coders review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care have not been met. Therefore, we decided that the Plan does not 
have to pay for inpatient hospital care provided from June 16, 2022, to July 11, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an inpatient psychiatric hospital stay 
provided from April 3, 2023, to April 18, 2023. 
 
You asked the Plan to reduce the copayment for an inpatient psychiatric hospital stay. You say that you were 
told the copayment would be considered under one 5-day 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 $315 
copayment per day for days 1 to 5 and $0 copayment for additional days for covered psychiatric hospital care 
and substance abuse services.  
 You have been asked to pay $1,476.35 for an inpatient psychiatric hospital stay, which is less than the standard 
copayment because the allowed amount per day was only $295.27 ($295.27 per day x 5 days = $1,476.35). 
This item/service falls within the inpatient services in a psychiatric hospital and substance abuse 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 reduce the copayment for an inpatient psychiatric hospital 
stay provided from April 3, 2023, to April 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided April 13, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you went to a provider, who explained that he 
did not pull teeth. You also say that you need your wisdom tooth pulled, as it was infected and decayed. 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 April 12, 2023. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided April 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 14, 2023. 
 
You asked the Plan to pay for an office visit. You say that the services should be covered. The Plan denied your 
request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on March 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 20, 2023. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary please reconsider. 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 an office visit provided 
on March 20, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested LTACH admission is 
medically necessary.  The Plan denied your request. The Plan says the enrollee does not meet all the 
requirements for admission to an LTACH.  
 
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 there are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. Transfer to the LTACH is not medically necessary as the enrollee 
is not yet stable for transfer and as it would not be clinically advantageous 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PushTracker E3 (K0108). 
 
You asked the Plan to pre-approve a PushTracker E3. You say that the denial o this item does not make the 
base or any other accessories unusable. You also say that this item is not an integral part of the base, thus a split 
decision should be possible. The Plan denied your request. The Plan says this is a convenience item and is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a PushTracker E3 (K0108).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L3 kyphoplasty. 
 
You asked the Plan to pre-approve kyphoplasty. You say that the enrollee has intractable pain and is unable to 
go about daily living. The Plan denied your request. The Plan says there is retropulsion noted and there are 
additional noted pathologies on imaging. 
 
The Plan follows Medicare rules. Medicare rules state that kyphoplasty surgery may be covered for vertebral 
compression fractures that have not responded to non-surgical medical management. 
 
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 kyphoplasty. Our reviewer says that the 
enrollee does not meet criteria for this procedure. Our physician reviewer found there is no trial of a back brace 
for fracture treatment. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve L3 kyphoplasty.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a limited oral evaluation (D0140) and a panoramic 
radiographic image (D0330) provided on March 3, 2023. 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered by the insurance. 
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 March 6, 2023. 
Therefore, we decided that the Plan does not have to pre-approve a limited oral evaluation (D0140) and a 
panoramic radiographic image (D0330) provided on March 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2392) provided on May 10, 2023. 
 
You asked the Plan to pay for a resin-based composite (D2392). You say that the office did not tell you they 
were out-of-network. 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 a resin-based composite 
(D2392) provided on May 10, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the abdominal ultrasound provided on 
November 30, 2022. 
 
You asked the Plan to waive the deductible for the abdominal ultrasound. You say that the deductible only 
applies to out-of-network services. 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. Your 
contract with the Plan says that there is a $1,000 deductible which applies to in-network outpatient diagnostic 
radiology services. Your contract with the Plan also says that you must pay a $140 copayment after meeting the 
deductible for outpatient diagnostic radiology services. 
 You have been asked to pay $133.62 towards the deductible. The item or service you asked the Plan to waive 
the deductible for falls within the outpatient diagnostic tests and therapeutic services benefit category. The Plan 
has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 deductible which applies 
to in-network outpatient diagnostic radiology services. This cost sharing is a contractual obligation that had not 
been met at the time the abdominal ultrasound was received on November 30, 2022. Therefore, we decided that 
the Plan does not have to waive the deductible for the abdominal ultrasound provided on November 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for osseous surgery (D4261) provided on April 19, 2023. 
 
You asked the Plan to pay for osseous surgery (D4261). You say that you would like reconsideration. The Plan 
denied your request. The Plan says according to your EOC, there is no coverage for osseous surgery (D4261). 
 
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 osseous 
surgery (D4261) provided on April 19, 2023.
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 services are medicallty necessary for the enrollee 
to recieve the services needed to return to their prior level of function. The Plan denied your request. The Plan 
says the enrollee does not meet the criteria for admission to an IRF.  
 
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 enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transcatheter aortic valve replacement (TAVR) procedures 
provided from January 20, 2023, to January 21, 2023. 
 
You asked the Plan to pay for TAVR. You say that you have reported the services at issue correctly. The Plan 
denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
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 TAVR have been met. Specifically, 
TAVR is provided only as part of a clinical trial called CED. The Plan contract states that if the enrollee 
already paid the Original Medicare cost-sharing amount, the Plan will reimburse the difference between what 
the enrollee paid and the in-network cost sharing. In this case, you have not provided documentation to show 
how much was paid for TAVR by Original Medicare. Therefore, we decided that the Plan does not have to pay 
for transcatheter aortic valve replacement (TAVR) procedures provided from January 20, 2023, to January 21, 
2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services. You say that you would like to request 
reconsideration of the denied claim and that the services requested are medically necessary. The Plan denied 
your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found based on the 
documentation provided, the health plans denial should be upheld.  The enrollee does not have documented, 
ongoing, home health physical therapy needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc-One. 
 You asked the Plan to pre-approve Synvisc-One. You say that the requested drug is medically necessary. The 
Plan denied your request. The Plan says a trial of other medications must be tried first.  
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Synvisc-One. Our reviewer says that 
the requested drug is not medically necessary. Our physician reviewer found you have not trialed Euflexxa and 
one of the following: Durolane, Gelsyn-3, or Supartz FX. Step therapy, as outlined by the Plan, requires that 
these be trialed first. The documentation does not outline contraindications or reasons these medications were 
not considered or that the Plans additional required drugs would likely be less effective and/or likely have 
adverse effects for you. Without the support of the documentation, Synvisc-One is not approved, as step criteria 
have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc-One.