Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to waive the coinsurance for the Part B drug injection provided on April 26, 2023. 
We decided that the Plan does not have to waive the coinsurance for the Part B drug injection provided on July 
18, 2023.  
 
You asked the Plan to waive the cost share for Part B drug injections provided on April 26, 2023, and July 18, 
2023. You say that you have been receiving this injection since 2021 and you have never had to pay $300 
coinsurance. The Plan says that this cost sharing was charged correctly. 
 
We decided that the Plan has to waive the coinsurance for the Part B drug injection provided on April 
26, 2023.  
 
The rules say a health 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 states that you pay 10% 
coinsurance up to $300 quarterly maximum for Medicare Part B chemotherapy drugs, associated 
administration, and all other Medicare Part B drugs. Documentation shows you received Medicare Part B 
injections on June 21, 2023, and May 24, 2023, which applied coinsurance of $299.87 and $0.13, for a total of 
$300. The cost share for June 21, 2023, and May 24, 2023, met your $300 quarterly maximum for April, May, 
and June. Therefore, we decided that the Plan has to waive the coinsurance for the injection provided on April 
26, 2023.  
 
We also decided that the Plan does not have to waive the coinsurance for the Part B drug injection 
provided on July 18, 2023. 
 
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 10% 
coin up to a $300 quarterly maximum for Medicare Part B chemotherapy drugs, associated administration, and 
all other Medicare Part B drugs. The records show you were charged $300 for the injection provided on July 
18, 2023. Therefore, we decided that the Plan does not have to waive the coinsurance for the injection provided 
on July 18, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 19, 2023, billed with 
codes 87486, 87498, 87502, 87581, 87634, 87640, 87651, and 87798. 
 
You asked the Plan to pay for the genetic testing billed. You say that the testing was medically necessary. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 

The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
The file shows that a respiratory panel was provided. We looked at the file and Medicare rules. This NGS panel 
was not billed with a single code as required. Based on this information, we decided that Medicare rules for 
coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to 
pay for the genetic testing provided on January 19, 2023, billed with codes 87486, 87498, 87502, 87581, 
87634, 87640, 87651, and 87798.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea. 
 You asked the Plan to pre-approve Eylea. You say that the enrollee had Avastin injections with no change. The 
Plan denied your request. The Plan says the enrollee has not tried the preferred agent.  
 
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 Eylea. Our physician reviewer found 
that the enrollee has a diagnosis of central retinal vein occlusion with macular edema in right eye. The Plan 
requires a trial of Byooviz after a trial and failure of Avastin before they will approve the requested drug. In 
this case, the enrollee has not tried and failed the required drug. There is no documentation provided indicating 
that the Plan's required drug would likely be less effective and/or likely have adverse effects 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 Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for scaling in presence of generalized moderate or severe 
gingival inflammation  full mouth after oral exam. (D4346) provided on February 27, 2023. 
 
You asked the Plan to pay for scaling in presence of generalized moderate or severe gingival inflammation  
full mouth after oral exam. . 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 pay for scaling in 
presence of generalized moderate or severe gingival inflammation  full mouth after oral exam. (D4346) provided on February 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A4215 and 99360 billed for date of service 
May 15, 2023. 
 
You asked the Plan to pay for the billed services. You say that you do not agree with the denial. The Plan 
denied your request. The Plan says no separate payment is made under the fee schedule. 

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure codes A4215 and 99360 have a Status Indicator of X on the Physician Fee Schedule. 
This means that no payment may be made under the physician fee schedule. 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 procedure codes A4215 and 99360 billed for date of service May 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for general adult medical examination provided on June 15, 
2023. 
 
You asked the Plan to pay for general adult medical examination. You say that you are requesting 
reconsideration for the denied claim. 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 general adult medical 
examination provided on June 15, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a platelet rich plasma injection (0232T). 
 
You asked the Plan to pre-approve a platelet rich plasma injection. You say that this is medically necessary. 
The Plan denied your request. The Plan says this 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 a platelet rich plasma injection. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this remains experimental for all orthopedic uses at this time. More 
research is needed. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a platelet rich plasma injection have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a platelet rich plasma injection (0232T).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pontic (D6245), crown-porcelain/ceramic (D6740) and 
surgical removal of erupted tooth (D7210) provided on August 9, 2023. 
 
You asked the Plan to pay for a pontic and crown-porcelain/ceramic. You say that this is medically necessary. 
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 pay for a pontic (D6245) and crown-porcelain/ceramic (D6740) provided on August 9, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for insertion of bladder catheter provided from August 29, 2022, 
to July 5, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for insertion of bladder catheter provided by an out-of-network provider. You say 
that you were not aware that the provider was out-of-network. The Plan denied your request. The Plan says 
services from non-participating providers are not covered unless they are authorized before the services are 
provided. 
 
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 insertion of bladder catheter provided from August 
29, 2022, to July 5, 2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames (V2025), purchased on June 30, 2023.  

You asked the Plan to pay for the frames. You say that the item should be covered. The Plan denied your 
request. The Plan says this item was purchased through a provider that is not in the Plan's vision network. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. Non-Medicare-covered routine eye exams and eyewear must be obtained from a provider in the Plan's 
vision vendor network. Services obtained from vendors outside this network are not covered. 
 
We looked at the file and the Plan's rules. This item was purchased through a provider that is not in the Plan's 
vision network. Based on this information, we decided that the Plan's rules for coverage of the frames have not 
been met. Therefore, we decided that the Plan does not have to pay for the frames (V2025), purchased on June 
30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival flap procedure, including root planing (D4241) 
provided on July 5, 2023. 
 
You asked the Plan to pay for gingival flap procedure, including root planing. 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 pay for gingival 
flap procedure, including root planing (D4241) provided on July 5, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311). 
 
You asked the Plan to pre-approve an electronic connection. You say that the item is medically necessary. The 
Plan denied your request. The Plan says the item 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 electronic connection. Our reviewer 
says that the requested item is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has adequate upper body strength to manage standard power drives. 
 
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 electronic connection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection (E2311).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography (CT) scan of the heart with calcium 
scoring provided on January 10, 2023. 
 
You asked the Plan to pay for the CT scan. You say that you were told the procedure would be covered and the 
claim is denying for medical equipment, but it was for a CT scan. The Plan denied your request. The Plan says 
the denial of payment for the CT scan is correct, because the enrollee is asymptomatic with a negative stress 
echo test. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 pay for the CT scan. Our reviewer says that the CT 
scan was not medically necessary. Our physician reviewer found that the CT calcium scoring is specifically 
designated as a non-covered test by Medicare so it would not be a covered benefit. The test is statutorily not 
covered by Medicare. Accordingly, this test (CPT 75571) cannot be approved and is denied. There is no 
evidence the test would be medically necessary as the enrollee was already known to have coronary artery 
disease and was asymptomatic. The test would not add additional diagnostic information. 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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pay for a computed tomography (CT) scan of the heart with calcium scoring provided on January 10, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental service (D6245) on April 13, 2023. 
 
You asked the Plan to pay for the dental service (D6245). You say that you would like to request 
reconsideration for payment. 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 13, 2023. 
Therefore, we decided that the Plan does not have to pay for the dental service (D6245) on April 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on March 8, 2023. 
 
You asked the Plan to pay for dental services. You say that you were not aware the 120-day submission 
requirement applied, and the denial should be reconsidered. The Plan denied your request. The Plan says the 
claim was not submitted for reimbursement within 120 days. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of dental services have not been met. Specifically, the claim was not submitted for reimbursement 
within 120 days. Therefore, we decided that the Plan does not have to pay for dental services provided on 
March 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care treatment provided on June 15, 2023. 
 
You asked the Plan to pay for wound care treatment. You say that you are requesting reconsideration for the 
denied claim. 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 wound care treatment 
provided on June 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve image-guided radiation therapy (IGRT). 
 
You asked the Plan to pre-approve IGRT. You say that the treatment request is for the prevention of additional 
future skin cancers. The Plan denied your request. The Plan says that picture studies are not supported to guide 
this type of treatment. 
 
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 IGRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found using ultrasound on a daily basis is not unreasonable to offer but is not necessary. Using daily 
image-guided radiation therapy (IGRT) for a technology for which the need has not been established is not 
necessary. This would not be furnished in accordance with accepted standards of medical practice. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IGRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve image-guided radiation therapy (IGRT).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a fluid circulating cold pad with pump (E0218) provided 
from April 26, 2023, to May 16, 2023. 
 
You asked the Plan to pay for a fluid circulating cold pad with pump. You say that this item was medically 
necessary. The Plan denied your request. The Plan says this item is not a covered benefit. The Plan must follow 
Medicare rules. Medicare rules say that a fluid circulating cold pad with pump (E0218) is not covered by 
Medicare. Therefore, we decided that the Plan does not have to pay for a fluid circulating cold pad with pump 
(E0218) provided from April 26, 2023, to May 16, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the duplex scan of extracranial arteries (93880). 
 
You asked the Plan to pre-approve the duplex scan of extracranial arteries. You say that the service is 
medically necessary. The Plan denied your request. The Plan says the enrollee has no symptoms and no 
physical examination findings to support medical necessity for this request.  
 
The Plan follows Medicare rules. Medicare rules say that non-invasive vascular studies done for screening 
purposes (i.e., without signs or symptoms of disease) are considered not reasonable and necessary and are 
therefore non-covered by Medicare.  
 
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 duplex scan of extracranial arteries. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee does 
not have any signs or symptoms for this service to be considered 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 duplex scan of extracranial arteries have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the duplex scan of extracranial arteries (93880).