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

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B prescription drugs 
provided on May 23, 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. Therefore, we decided that the Plan does not have to waive the coinsurance 
for Medicare Part B prescription drugs provided on May 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical placement of implant body (D6010) for 
teeth numbers 9 and 10. 
 
You asked the Plan to pre-approve the dental services. You say that due to situations beyond your control, the 
procedure which you already had an authorization for could not be performed. 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 an authorization for the requested item or service was exhausted for date of service from 
August 16, 2023, to November 14, 2023. Therefore, we decided that the Plan does not have to pre-approve the 
surgical placement of implant body (D6010) for teeth numbers 9 and 10.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on April 
27, 2023. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you refuse to pay for 
this visit based on the treatment you received. 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 physician/practitioner services. 
 
You have been asked to pay a $20 copayment for the specialist office visit. This item/service falls within the 
physician/practitioner 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 copayment for 
the specialist office visit provided on April 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service January 21, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says payment for code 81456 is bundled into payment for code 81455. 
 
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 81456 is a column II code to column I code 81455 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 81456 billed for date of service January 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network internal medicine visit. 
provided on May 18, 2023, to August 15, 2023. 
 
You asked the Plan to waive the copayment for an in-network internal medicine visit.. You say that this was a 
routine visit, and should not have a 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 $10 
copayment for Physician/Practitioner services, including doctors officevisits. 
 
You have been asked to pay a $10 copayment for an in-network internal medicine visit.. This item/service falls 
within the Physician/Practitioner services, including doctors officevisits 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 copayment for an in-network internal medicine visit. provided on May 18, 2023, to 
August 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140), retainer 
crown - porcelain/ceramic tooth (D6740 x3), and pontic - porcelain/ceramic (D6245) provided on March, 7, 
2023, to May 31, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were unaware that bridges were only 
covered once every five years. The Plan denied your request. The Plan says your benefit for the requested 
services 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 limited oral evaluation - problem focused was exhausted on date of service February 
15, 2023. The record also shows that you benefit for the retainer crown - porcelain/ceramic and pontic - 
porcelain/ceramic was exhausted on the March 7, 2023. Therefore, we decided that the Plan does not have to 
pay for a limited oral evaluation - problem focused (D0140), retainer crown - porcelain/ceramic tooth (D6740 
x3), and pontic - porcelain/ceramic (D6245) provided on March, 7, 2023, to May 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the medical eye exam (99204) provided on 
June 26, 2023. 
 
You asked the Plan to waive the copayment for the medical eye exam (99204). You say that the service should 
be covered. 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 $35 
copayment for vision services. 
 
You have been asked to pay a $35 copayment for the medical eye exam (99204). This item/service falls within 
the vision 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 copayment for the medical eye 
exam (99204) provided on June 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87506 billed for date of service April 27, 
2022. 
 
You asked the Plan to pay for procedure code 87506. You say that this service was necessary and was reported 
appropriately. The Plan denied your request. The Plan says this code is not supported in the medical record. 
 
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 87506 is infectious agent detection by nucleic acid (DNA 
or RNA); gastrointestinal pathogen (e.g., Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, 
Giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, 
multiple types or subtypes, 6-11 targets. 
 
 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 procedure code 87506. Our reviewer says that this code is 
not supported in the medical record. Our reviewer found the record states that more than 11 antigens were 
tested; there is a more appropriate code for the number of antigens tested. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 87506 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 87506 billed for date of service April 27, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Amlodipine. 
 
You asked the Plan to pre-approve Amlodipine. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Amlodipine.  Benefits for Amlodipine may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87481, 87491, 87500, 87563, 87640, 87641, 
87653, 87798) provided on June 11, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed codes. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the lab services have been met. No 
clinical documentation was submitted to support the codes billed. Additional information was requested by the 
plan and none was provided. Therefore, we decided that the Plan does not have to pay for lab services (87481, 
87491, 87500, 87563, 87640, 87641, 87653, 87798) provided on June 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a 100-day blood sugar testing supplies. 
 
You asked the Plan to pre-approve blood sugar testing supplies. You say that the enrollee needs this supply. 
The Plan denied your request. The Plan says this item is available as a recurring 90-day supply. 
 
The Plan must follow Medicare rules. Medicare rules say that suppliers may dispense up to a ninety (90) day 
supply.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of blood sugar testing supplies have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a 100-day blood sugar testing supplies.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87506 billed for date of service April 19, 
2022. 
 
You asked the Plan to pay for procedure code 87506. You say that this service was necessary and was reported 
appropriately. The Plan denied your request. The Plan says this code is not supported in the medical record. 
 
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 87506 is infectious agent detection by nucleic acid (DNA 
or RNA); gastrointestinal pathogen (e.g., Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, 
Giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, 
multiple types or subtypes, 6-11 targets. 
 
 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 procedure code 87506. Our reviewer says that this code is 
not supported in the medical record. Our reviewer found the record states that more than 11 antigens were 
tested. There is a more specific code for the number of antigens tested. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 87506 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 87506 billed for date of service April 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that due to the complexity of the enrollee and 
prior hospitalization, they will continue to require acute care for a period of time before they will be safe 
enough to transition to a lower level of care. The Plan denied your request. The Plan says an LTACH 
admission is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is not stable for transfer to an LTACH as their needs can be met at 
the current facility. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sclerotherapy. 
 
You asked the Plan to pre-approve sclerotherapy. You say that the enrollee has light burning and itching in his 
lower left extremity and believe this would be the best treatment for him. The Plan denied your request. The 
Plan says this does not meet the criteria for coverage. 
 
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 sclerotherapy. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found there is no documentation of six weeks of conservative therapy. Therefore, the request is deemed not medically reasonable and 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 sclerotherapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sclerotherapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve biologic material to aid in soft and osseous tissue 
regeneration (D4265). 
 
You asked the Plan to pre-approve biologic material to aid in soft and osseous tissue regeneration. 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 pre-approve 
biologic material to aid in soft and osseous tissue regeneration (D4265).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 19, 2022. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary and should be covered. 
The plan did not pay enough. 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 February 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve resin-based composites (D2392 and D2393). 
 
You asked the Plan to pre-approve resin-based composites. 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 pre-approve 
resin-based composites (D2392 and D2393).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lucentis. 
 You asked the Plan to pre-approve Lucentis. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
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 Lucentis. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has a diagnosis of exudative age-related macular degeneration with chorodial 
neovascularization. The documentation does not support that the enrollee has tried and failed Byooviz. The 
documentation does not support that Byooviz would likely be less effective and/or likely have adverse effects 
for the enrollee. Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Lucentis have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Lucentis.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services and mileage provided on June 19, 
2023. 
 
You asked the Plan to pay for the ambulance services and mileage. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says two of the billed diagnosis codes cannot be reported 
together. 
 The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that J80 (acute respiratory distress syndrome) has an Excludes1 note in relation 
to R06.02 (shortness of breath). This means that the two diagnosis codes cannot be reported together. Based on 
this information, we decided that the Medicare billing rules for the ambulance services and mileage have not 
been met. Therefore, we decided that the Plan does not have to pay for the ambulance services and mileage 
provided on June 19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a targeted genomic sequence analysis panel provided on 
April 26, 2023, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the targeted genomic sequence analysis panel provided OON. You say that the 
enrollee's physician ordered this panel to help determine the best course of treatment for the enrollee's specific 
cancer and clinical presentation. You say that the documentation provided supports that the test was medically 
necessary. The Plan denied your request. The Plan says the services were non-urgent and could have been 
provided in-network. 
 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 services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these OON services. Therefore, 
we decided that the Plan does not have to pay for a targeted genomic sequence analysis panel provided on April 
26, 2023, by an out-of-network (OON) provider.