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

 
We decided that the Plan does not have to pay for the crown - porcelain/ceramic (D2740) provided on May 1, 
2023. 
 
You asked the Plan to pay for the core buildup and crown - porcelain/ceramic. You say that the provider told 
you that you would be covered for the services received prior to receiving them. You also say that you cannot 
afford this bill. The Plan denied your request. The Plan says your benefit for the crown - porcelain/ceramic 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 Plan's 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 crown - porcelain/ceramic was exhausted on date of service April 8, 2021 under the 
dental service represented by code (D2644). Therefore, we decided that the Plan does not have to pay for the 
crown - porcelain/ceramic (D2740) provided on May 1, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 36556 and 76937 provided on February 18, 2023. 
 
You asked the Plan to pay for codes 36556 and 76937. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says the records do not support these codes. 
 
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 36556 is insertion of non-tunneled centrally inserted 
central venous catheter; age 5 years or older. The CPT Code Manual definition of code 76937 is ultrasound 
guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent real-time ultrasound visualization of vascular needle entry, with permanent 
recording and reporting. 
 
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 codes 36556 and 76937. Our reviewer says that these codes 
do not meet criteria for payment. Our reviewer found the procedure report does not include sufficient 
documentation to verify procedure code 36556 has been performed.  Per CPT guidelines "To qualify as a 
central venous access catheter or device, the tip of the catheter/device must terminate in the subclavian, 
brachiocephalic (innominate) or illiac veins, the superior or inferior vena cava, or the right atrium".  Therefore, 
this procedure cannot be verified. The procedure report does not include documentation of ultrasound guidance 
for vascular access requiring ultrasound evaluation of potential access sites, documented of selected vessel 
patency, concurrent real-time ultrasound visualization of vascular needle entry, with permanent recording and 
reporting.  In this case, the following was not found documented in the medical record: 
Ultrasound evaluation of possible access sites; Patency of the selected vessel; Realtime visualization of the 
vascular needle entry; Permanent recording of images and reporting. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 36556 and 76937 have not been met. Therefore, we decided that the Plan 
does not have to pay for codes 36556 and 76937 provided on February 18, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the needle electromyography (95886) and nerve conduction 
studies (95913) provided on April 12, 2023. 
 
You asked the Plan to pay for the needle electromyography and nerve conduction studies . You say that your 
pain management doctor ordered this test, not your chiropractor. You also say that you feel this should be 
covered because the test was ordered by my pain management doctor for pain in your arms and legs, to 
diagnose your condition. The Plan denied your request. The Plan says as these services were performed by a 
chiropractor, reimbursement will not be provided. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
 
 
 
 
 The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the needle electromyography (95886) and nerve conduction studies 
(95913) provided on April 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant maintenance procedures (D6080 x 5). 
 
You asked the Plan to pre-approve the dental services. You say that these procedures are necessary for stability, 
masticatory efficiency, and the enrollee's quality of life. 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 Plan's 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 authorization 0045432754. Therefore, 
we decided that the Plan does not have to pre-approve implant maintenance procedures (D6080 x 5).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the shoulder arthroplasty. 
 
You asked the Plan to pre-approve the shoulder arthroplasty. You say that the surgery is medically necessary. 
The Plan denied your request. The Plan says  the shoulder arthroplasty 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 shoulder arthroplasty. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee was being treated for primary osteoarthritis of the right shoulder. The detailed 
documentation is not evident regarding significant rotator cuff pathology on the diagnostic imaging provided 
for review. There are limited large-scale, long-term references showing the safety and efficacy of the requested 
surgery in this clinical setting. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested right reverse shoulder 
arthroplasty is not medically reasonable or 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 shoulder arthroplasty have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the shoulder arthroplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infusion services (96365, 96366, 96521) provided on 
February 1, 2023. 
 
You asked the Plan to pay for the infusion services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that services comprising an Outpatient Intravenous 
Insulin Therapy regimen are nationally non-covered under Medicare. 
 
We looked at the file and Medicare rules. The services provided are not covered under Medicare. Based on this 
information, we decided that Medicare rules for coverage of the infusion services have not been met. 
Therefore, we decided that the Plan does not have to pay for infusion services (96365, 96366, 96521) provided 
on February 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365, 96366, 96521, and J1817 provided 
on February 14, 2023. 
 
You asked the Plan to pay for procedure codes 96365, 96366, 96521, and J1817. 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 as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 96365 is intravenous infusion, for therapy, prophylaxis, 
or diagnosis (specify substance or drug); initial, up to 1 hour. The definition of code 96366 is intravenous 
infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List 
separately in addition to code for primary procedure). The definition of code 96521 is refilling and maintenance 
of portable pump. The definition of code J1817 is insulin for administration through DME (i.e., insulin pump) 
per 50 units. 
 
We find that CPT codes 96365, 96366, 96521, and J1817 are not supported in the medical record. Specifically, 
the records show that outpatient intravenous insulin treatment (OIVIT) was performed and there is a more 
appropriate set of codes for these services. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 96365, 96366, 96521, and J1817 provided on February 14, 2023.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve an abdominal lipectomy/panniculectomy. 
 
You asked the Plan to pre-approve abdominal lipectomy/panniculectomy. You say that you need this surgery. 
The Plan denied your request. The Plan says that the medical criteria for this procedure have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve abdominal lipectomy/panniculectomy. 
Our reviewer says that the requested items/services are considered medically reasonable and necessary in this 
case. Our physician reviewer found provided medical records document a pannus or panniculus that hangs 
below the level of the pubis, and the medical records document that the panniculus causes chronic intertrigo 
that consistently recurs or remains refractory to appropriate medical therapy over a period of 3 months. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of abdominal lipectomy/panniculectomy have been met. Therefore, we decided 
that the Plan has to pre-approve an abdominal lipectomy/panniculectomy.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram provided on April 11, 
2023. 
 
You asked the Plan to waive the copayment for an electrocardiogram. You say that you disagree with the 
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 $20 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $20 copayment for an electrocardiogram. This item/service falls 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. However, since the allowed amount is less than the 
standard copayment, you only owe $16.37. Therefore, we decided that the Plan does not have to waive the 
copayment for an electrocardiogram provided on April 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an esophagogastroduodenoscopy (43239) provided on March 
15, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the esophagogastroduodenoscopy provided OON  . You say that the records 
provided support the services in dispute.  The Plan denied your request. The Plan says the enrollee does not 
have OON benefits.  
 
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 an esophagogastroduodenoscopy (43239) 
provided on March 15, 2023, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for out-of-network outpatient diagnostics tests 
provided on February 03, 2023. 
 
You asked the Plan to waive the coinsurance for out-of-network outpatient diagnostics tests. You say that you 
disagree with the coinsurance. 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 35% 
coinsurance for out-of-network outpatient diagnostics test. 
 
You have been asked to pay 35% coinsurance for out-of-network outpatient diagnostics tests. This item/service 
falls within the out-of-network outpatient diagnostics test 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 total allowed amount for the outpatient 
diagnostics test is $470.43. You are being asked to pay $164.64 ($470.43 x 35% = $164.64). Therefore, we 
decided that the Plan does not have to waive the coinsurance for out-of-network outpatient diagnostics tests 
provided on February 03, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365 and 96366 provided on March 29, 
2023. 
 You asked the Plan to pay for procedure codes 96365 and 96366. 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 OIVIT is not covered.  
 
The records indicate that the services at issue in this case were for the purpose of outpatient intravenous insulin 
therapy. Based on this information, we decided that Medicare rules for coverage of the services have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 96365 and 96366 provided 
on March 29, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the PT visits. You say that the enrollee's PT has addressed their functional 
impairments and is needed at this time to prevent further decline and maintain as much independence as 
possible. The Plan denied your request. The Plan says the services are not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the PT visits. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee has previously been treated with outpatient therapies and 
should be independent with a home exercise program. There is no documentation of a recent injury or decline 
in function. The additional therapy services are not an appropriate duration and frequency for treatment of the 
enrollees medical condition and therefore are 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 PT visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional physical therapy (PT) visits.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment, no transport provided on 
November 22, 2022. 
 
You asked the Plan to pay for ambulance response and treatment, no transport. You say that you tripped on 
cement in a parking lot and as a result of this accident, you were excessively bleeding and had to call an 
ambulance as you could have a concussion or a brain bleed. You say that the ambulance came and treated you 
and told you that you had an option to be transported to the hospital, but they didn't feel it was necessary at the 
time. The Plan denied your request. The Plan says the Medicare ambulance benefit is a transportation benefit 
and without transport there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on November 22, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport 
provided on November 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on January 24, 2022. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says payment 
for services that were not received within 12 months or 1 calendar year from the date the services were 
furnished. 
 
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 the physician's services was not filed until March 27, 2023. 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 physician's services provided on January 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and related services provided on January 13, 
2023. 
 
You asked the Plan to pay for an office visit and related services. 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 and 
related services provided on January 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 10, 2023. 
 
You asked the Plan to pay for an office visit. You say that if you had known this provider was out-of-network, 
you would not have gone to see them. 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 January 10, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B prescription drugs 
provided on April 12, 2023. 
 
You asked the Plan to waive the coinsurance for Medicare Part B prescription drugs. You say that you disagree 
with the coinsurance. 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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for Medicare Part B prescription drugs. This item/service falls 
within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The total allowed amount for the prescription drugs is $2,142.15. You are 
being asked to pay $428.43 ($2,142.15 x 20% = $428.43). Therefore, we decided that the Plan does not have to 
waive the coinsurance for Medicare Part B prescription drugs provided on April 12, 2023.