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

 
We decided that the Plan does not have to pre-approve the VIA Disc NP procedure. 
 
You asked the Plan to pre-approve the procedure. You say that this procedure is necessary to address pain and 
restore function. The Plan denied your request. The Plan says experimental and investigational procedures are 
not covered. 
 
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 procedure. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the VIA Disc NP procedure is considered experimental/investigational and is not medically 
necessary for the treatment of chronic low back pain. 
 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 procedure.  have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the VIA Disc NP procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345-GZ billed for date of service April 11, 
2023. 
 You asked the Plan to pay for procedure code 81345-GZ. You say that you request for an overturn f the denial 
and reprocessing of the claim. The Plan denied your request. The Plan says payment for code 81345-GZ is 
bundled into payment for code 0089U. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 
81345-GZ is a column II code to column I code 0089U. This claim has not been billed with an appropriate 
modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 81345-GZ billed for date of 
service April 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (87798-XU) provided June 20, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not supported by the records. 
 
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 87798 is infectious agent detection by nucleic acid (DNA 
or RNA), not otherwise specified; amplified probe technique, each organism. 
 
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 the laboratory service. Our reviewer found for code 87798, 
the provided records in this case do not document what specific testing was covered by the not otherwise 
specified code. The validity of the code cannot be verified based on the records provided.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory service (87798-XU) provided June 20, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve core buildup services for teeth #27 and #28. 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says that the services denied correctly as they 
do not meet the clinical requirements to be approved. 
 
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 the dental 
services 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 the dental services. Our physician 
reviewer found that the review of the documentation indicates that tooth #28 has significant breakdown due to 
caries and fracture to warrant a core buildup to provide adequate support and retention for a crown 
restoration. Tooth #27 demonstrates an incisal breakdown and a short clinical crown. Criteria are met. 
 
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 the dental services have been met. Therefore, we decided that the Plan has to 
pre-approve core buildup services for teeth #27 and #28.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the x-rays, a specialist office visit, and the 
urgent care visit provided from June 20, 2023, to July 11, 2023. 
 
You asked the Plan to waive the copayments for the x-rays, a specialist office visit, and the urgent care visit. 
You say that you were unaware of the copayments. 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 $30 
copayment for each x-ray service. Your contract with the Plan also clearly says that you must pay a $50 
copayment for specialty care physician services. Your contract with the Plan also clearly says that you must 
pay a $50 copayment for urgently needed services. 
 
You have been asked to pay a $30 copayment for each x-ray provided on June 20, 2023, July 8, 2023, and July 
11, 2023. These items/services fall within the outpatient diagnostic tests and therapeutic services and supplies 
benefit category. You have also been asked to pay $50 copayment for the specialist office visit provided on 
July 11, 2023. This item/service falls within the physician/practitioner services, including doctors office visits 
benefit category. You have also been asked to pay a $50 copayment for the urgently care visit provided on July 
8, 2023. This item/service falls within the urgently needed services benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayments for the x-rays, a specialist office visit, and the urgent care visit provided from June 20, 
2023, to July 11, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 33508 performed on May 25, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code - 33508-XU (1 unit) remains not supported. 
 
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 33508 is "Endoscopy, surgical, including video-assisted 
harvest of vein(s) for coronary artery bypass procedure (List separately in addition to code for primary 
procedure)." 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that CPT 33508 was reported with modifier XU. The procedure report describes coronary artery bypass graft with reverse saphenous vein graft. In 
this case, harvesting of the saphenous vein for a vein bypass or in-situ bypass is included and not separately 
billable. The operative report does not support upper extremity or femoropopliteal vein harvest. Therefore, the 
procedure code and modifier reported cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. 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 code 33508 performed on May 25, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mental health services provided on August 08, 2023. 
 
You asked the Plan to pay for mental health services. You say that this should be paid for. 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 mental health services 
provided on August 08, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on July 26, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the office visit. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says the service was not authorized. 
 
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 the office visit provided on July 26, 2023, by an 
OON provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transportation provided on May 22, 2023. 
 
You asked the Plan to pay for the ambulance transportation. You say that you are requesting reconsideration of 
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 the ambulance 
transportation provided on May 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Tylenol acetaminophen extra strength 500 purchased on June 
24, 2023. 
 
You asked the Plan to pay for Tylenol acetaminophen extra strength 500. You say that you do not understand 
how you went over the balance of $4.37 since you paid the balance with your cash or card. The Plan denied 
your request. The Plan says this benefit was exhausted on June 24, 2023. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and Tylenol 
acetaminophen extra strength 500 is an OTC item. Therefore, we decided that the Plan does not have to pay for 
Tylenol acetaminophen extra strength 500 purchased on June 24, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to issue reimbursement for the hearing aid charger (V5267) purchased on  
April 19, 2023. 
 
You asked the Plan to issue reimbursement for this item. You say that you are requesting a reconsideration of 
the Plan's denial for payment. The Plan denied your request. The Plan says that a hearing aid charger is not a 
covered benefit.  
 
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 Plans contract submitted to our organization does not contain 
information regarding your hearing aid benefit. The Plan has not substantiated their denial; therefore, we must 
find in your favor. Therefore, we decided that the Plan has to issue reimbursement for the hearing aid charger 
(V5267) purchased on April 19, 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: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for retainers on teeth #10 and #11 appear to be intact. The criteria for 
D6740 on these teeth have not been met.". We decided that the Plan does not have to pay for the rest of the 
services.  
 
You asked the Plan to pay for the core buildups (D2950x4) on tooth #12, #14, #10, and #11, the retainer 
crowns (D6740) on tooth #10, #11, and #12, the fixed partial denture sectioning (D9120) on tooth #11. You say 
that this is medically necessary. The Plan says that this does not meet the criteria. 
 
We decided that the Plan has to pay for retainers on teeth #10 and #11 appear to be intact. The criteria 
for D6740 on these teeth have not been met.".  
 
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 substantiated their denial for D6740 on tooth #12. The plan has not explained why and on 
what basis they are downgrading the request for D6740 to D6752. The plan has also not specified what benefit 
has been exhausted and has not provided proof of any benefit being exhausted. Based on this information, we 
decided that Medicare rules for coverage of this service has been met. Therefore, we decided that the Plan has 
to pay for retainers on teeth #10 and #11 appear to be intact. The criteria for D6740 on these teeth have not 
been met.".  
 
We also decided that the Plan does not have to pay for the rest of the services. 
 
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. The Plan covers dental 
services when the services are medically necessary and reasonable. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the core buildups (D2950 x4) for teeth 
#10, #11, #12, and #14, and the fixed partial denture sectioning (D9120) for tooth #11 are not among those 
covered under this benefit. 
 
Additionally, 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 D6740 on tooth #12. Our reviewer 
found that the retainers on teeth #10 and #11 appear to be intact. The criteria for D6740 on these teeth 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 the services at issue have not been met. Therefore, we decided that the Plan 
does not have to pay for the rest of the services. 
 
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 waive the copayment for the inpatient hospital stay provided on July 
30, 2023, to August 01, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you received poor care 
during your stay. 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 $390 
copayment for inpatient hospital care. 
 
You have been asked to pay a $390 copayment for the inpatient hospital stay. This item/service falls within the inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. You have been asked to pay a total of $780 for the inpatient hospital stay ($390 copayment 
x 2 days = $780). You have not been charged for the day you were discharged. Therefore, we decided that the 
Plan does not have to waive the copayment for the inpatient hospital stay provided on July 30, 2023, to August 
01, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the physical therapy service to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve the physical therapy. You say that you feel more comfortable at the out-of-
network facility. The Plan denied your request. The Plan says the physical therapy can be approved with an in-
network provider. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the physical therapy service to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain or ceramic crown (D2740) for teeth numbers 
22, 23, and 24. 
 
You asked the Plan to pre-approve a porcelain or ceramic crown (D2740) for teeth numbers 22, 23, and 24. 
You say that these teeth were fractured off and need to be restored with crowns. The Plan denied your request. 
The Plan says the criteria has not been met for crowns (D2740) on teeth numbers 22, 23, and 24.  
 
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 a porcelain or 
ceramic crown (D2740) for teeth numbers 22, 23, and 24 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 a porcelain or ceramic crown (D2740) 
for teeth numbers 22, 23, and 24. Our reviewer says that based off the information that was provided, a 
porcelain or ceramic crown (D2740) for teeth numbers 22, 23, and 24 is not medically reasonable or necessary. 
Our physician reviewer found the periapical x-rays show that there is wear on teeth numbers 22, 23, and 24. 
Our physician reviewer also found that from the x-rays, it does not look like there is pulp exposure of these 
teeth requiring the need for root canal treatment, since there is still tooth structure between  the edges of the 
teeth of numbers 23, 24 and the pulp. Our physician reviewer also found that there is no documentation that 
would show the necessity of these teeth needing root canal treatment. 
 
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 a porcelain or ceramic crown (D2740) for teeth numbers 22, 23, and 24 have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a porcelain or ceramic crown 
(D2740) for teeth numbers 22, 23, and 24.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for on office visit provided on June 16, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says their original decision to deny payment was correct. 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 on office visit provided on June 16, 2023, by an 
out-of-network (OON) provider.