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

 
We decided that the Plan does not have to pay for the computed tomography (CT). provided on July 24, 2023. 
 
You asked the Plan to pay for the computed tomography (CT).. You say that the services were medically 
necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the computed 
tomography (CT). provided on July 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two (2) intraoral - periapical additional radiographic 
images (D0230) provided on September 6, 2023.  

You asked the Plan to pay for the dental services. You say that the x-rays were needed to accurately diagnosis 
your condition and to address your health and dental needs. The Plan denied your request. The Plan says your 
benefit for the requested 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 service was exhausted on date of service September 6, 2023. Therefore, 
we decided that the Plan does not have to pay for the two (2) intraoral - periapical additional radiographic 
images (D0230) provided on September 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified restorative procedure (D2999) and a custom 
fabricated abutment (D6057) provided on July 11, 2023, to July 13, 2023 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says these services have been processed correctly. 
 
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 annual dental allowance amount was exhausted on date of service July 11, 2023. This benefit does 
not include D2999. Therefore, we decided that the Plan does not have to pay for an unspecified restorative 
procedure (D2999) and a custom fabricated abutment (D6057) provided on July 11, 2023, to July 13, 2023
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99231 billed for date of service June 16, 
2023. 
 You asked the Plan to pay for procedure code 99231. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 99231 is bundled into 
payment for code 99238. 
 
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 99231 
is a column II code to column I code 99238. 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 99231 billed for date of service June 16, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kimysra. 
 
You asked the Plan to pre-approve Kimysra. You say that the enrollee needs to avoid hospital admission. The 
Plan denied your request. The Plan says the drug is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Kimysra. Our reviewer says that the 
requested drug is not medically necessary. Our physician reviewer found the use of Kimysra is not FDA- 
approved for the enrollee's diagnosis. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Kimysra have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Kimysra.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care. provided on October 31, 2023. 
 
You asked the Plan to pay for nursing facility care.. You say that you would like reconsideration based on the 
records submitted. 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 nursing facility care. 
provided on October 31, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the records do not show why the enrollee needs to move to a skilled nursing 
facility for the remainder of their care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 04, 2023. 
 
You asked the Plan to pay for an office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on April 04, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the walking boot (L4361) provided on July 21, 2023. 
 
You asked the Plan to pay for the walking boot. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says the KX modifier is required on this claim. The Plan must follow Medicare rules. Medicare rules say that the KX modifier is required to show all the 
criteria have been met for the AFO/KAFO base and addition codes. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the walking boot have not been met. Specifically, the record shows this claim was billed without 
the required KX modifier. Therefore, we decided that the Plan does not have to pay for the walking boot 
(L4361) provided on July 21, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayments for the services provided from January 3, 2023, to June 
26, 2023.  
 
You asked the Plan to waive the copayments for these services. You say that you reached your maximum out-
of-pocket amount prior to these services. The Plan denied your request. The Plan says that the cost share was 
applied correctly. 
 
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. We find that the Plan has not provided an Explanation of Benefits (EOB) or 
other documentation showing how the cost sharing was applied.  Therefore, we decided that the Plan has to 
waive the copayments for the services provided from January 3, 2023, to June 26, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the annual wellness visit (AWV) (G0439) provided on 
September 7, 2023. 
 
You asked the Plan to pay for the AWV. You say that this is always covered by Medicare and your secondary 
medical insurance. You also say that this appointment was needed for you to stay healthy. The Plan denied 
your request. The Plan says the benefit for this service has been exhausted. 
 
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once 
every 12 months.  
 
Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. 
Therefore, we decided that the Plan does not have to pay for the annual wellness visit (AWV) (G0439) 
provided on September 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99401 billed for date of service August 31, 
2023. 
 
You asked the Plan to pay for procedure code 99401. You say that the service should be covered. The Plan 
denied your request. The Plan says this is a non-covered service. 
 
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 code 99401 has a Status Indicator of N on the Physician Fee Schedule. This means that 
procedure code 99401 is a non-covered service. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99401 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99401 billed for date of service August 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) provided on August 25, 2023. 
 
You asked the Plan to pay for the office visit. You say that the cost share was wrong. 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 $100 deductible which applies to Physician/Practitioner Services, 
including Doctors Office Visits.  
 
The item or service you asked the Plan to pay for falls within the Physician/Practitioner Services, including 
Doctors Office Visits benefit category. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is a $100 deductible which applies to Physician/Practitioner Services, including Doctors 
Office Visits. This cost sharing is a contractual obligation that had not been met at the time the office visit was 
received on August 25, 2023. Therefore, we decided that the Plan does not have to pay for the office visit 
(99214) provided on August 25, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), anesthetic agent(s) and/or steroid; genicular 
nerve branches, including imaging guidance, when performed (64454). 
 
You asked the Plan to pre-approve injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, 
including imaging guidance. 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 injection(s), anesthetic agent(s) and/or 
steroid; genicular nerve branches, including imaging guidance. Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found genicular nerve blocks and genicular nerve ablations are considered investigational and not medically 
necessary for the treatment of chronic knee 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 injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, 
including imaging guidance have not been met. Therefore, we decided that the Plan does not have to pre-
approve injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, including imaging guidance, 
when performed (64454).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of the brain to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve an MRI of the brain. You say that the requested imaging is medically 
necessary. The Plan denied your request. The Plan says the enrollee must receive their care from a 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 
an MRI of the brain to be provided by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planning (D4341). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. 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 July 31, 2023, and 
August 18, 2023. Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root 
planning (D4341).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) colonography. 
 You asked the Plan to pre-approve CT colonography. You say that the enrollee would prefer to have a virtual 
colonography. The Plan denied your request. The Plan says the enrollee has not had a colonoscopy in more 
than 10 years and there is no indication of a doctor's evaluation. 
 
The Plan follows Medicare rules. Medicare rules state that CT colonography may be covered under certain 
circumstances. 
 
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 CT colonography. Our reviewer says 
that the enrollee does not meet criteria for a CT colonography. Our physician reviewer found the records do not 
document an incomplete colonoscopy or that an optical colonoscopy cannot be safely attempted. Additionally, 
the CT colonography has been ordered as an alternative to an instrument colonoscopy which is not allowed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CT colonography have not been met. Therefore, we decided that the Plan does 
not have to pre-approve computed tomography (CT) colonography.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 16 home health skilled nursing visits 
(G0299), and an additional 16 home health speech therapy visits (G0153). 
 
You asked the Plan to pre-approve home health services. You say that this is 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 the 
documentation shows that the enrollee has met all appropriate home health speech therapy goals. The 
documentation does not specify any acute clinical status changes, acute or worsening wounds, medication or 
plan of care changes. The records do not show that the requested services are required to effectively provide 
treatment, care, and/or services in order to improve the enrollee's level of function, or to establish/perform a 
maintenance program to maintain the enrollee's level of function and/or prevent deterioration. 
 
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 an additional 16 home health skilled nursing visits (G0299), and an additional 16 
home health speech therapy visits (G0153).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the cone beam computed tomography (CT) 
capture and interpretation with field of view of both jaws; with or without cranium (D0367) provided on  
May 9, 2023. 
 
You asked the Plan to issue reimbursement for this service. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says this service is not a covered 
benefit under the supplemental dental policy.  
  
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, the service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to issue reimbursement for 
the cone beam computed tomography (CT) capture and interpretation with field of view of both jaws; with or 
without cranium (D0367) provided on May 9, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the duplex scan, coded 93880, billed for date of service 
August 4, 2023. 
 
You asked the Plan to pay for the billed service. You say that the records show medical necessity. The Plan 
denied your request. The Plan says the test is not covered for screening purposes. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The file shows that a duplex scan of extracranial arteries was provided. The service was billed with diagnosis 
code Z82.49, defined as family history of ischemic heart disease. The test at issue was requested for screening 
purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does 
not have to pay for the duplex scan, coded 93880, billed for date of service August 4, 2023.