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

 
We decided that the Plan does not have to pay more for the intraoral radiographic images (D0220 and D0230), 
bitewings (D0274), a cleaning (D1110), and resin-based composites (D2332 and D2392) for tooth #6, #15, and 
#21 provided by an out-of-network provider on September 19, 2022, to September 26, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you believe that the Plan should honor 
your request and pay the claim. The Plan denied your request. The Plan says you are responsible for any 
charged amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. 
 
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. 
 For the intraoral radiographic image (D0220) the total amount billed was $38 and the total allowed amount was 
$27 which the Plan paid leaving a difference of $11 ($38 billed - $27 allowed). For the intraoral radiographic 
image (D0230) the total amount billed was $16 and the total allowed amount was $15 which the Plan paid 
leaving a difference of $1 ($16 billed - $15 allowed). For the bitewings (D0274) the total amount billed was 
$97 and the primary insurance paid $86.40 which is more then the allowed amount of $32. For the cleaning 
(D1110) the total amount billed was $125 and the primary insurance paid $111.20 which is more then the 
allowed amount of $55. For the resin-based composite (D2332) the total amount billed was $362 and the 
primary insurance paid $226.80 which is more then the allowed amount of $152. For the resin-based composite 
(D2392) the total billed amount was $319 and the primary insurance paid $194.40 which is more then the 
allowed amount of $83. For the other resin-based composite (D2392) the total amount billed was $319 and the 
primary insurance paid $194.40 which is more then the allowed amount of $83. You have been asked to pay 
the difference between the out-of-network providers charges and the Plans payment and the difference in 
what the primary insurance paid and what the allowed amount for the dental services were. 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 pay more for the intraoral radiographic images (D0220 and D0230), bitewings (D0274), a 
cleaning (D1110), and resin-based composites (D2332 and D2392) for tooth #6, #15, and #21 provided by an 
out-of-network provider on September 19, 2022, to September 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need physical and occupational therapy and are 
capable of completing both. You say the skilled nursing facility you are currently in is no longer providing any 
type of physical or occupational therapy. The Plan denied your request. The Plan says you do not meet the 
Medicare criteria for admission to an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 
Our physician reviewer found that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical and/or occupational therapy, there 
is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to waive the coinsurance for the injection provided on January 9, 2023. We also 
decided that the Plan does not have to reduce the copayment for the myocardial perfusion imaging provided on 
January 9, 2023.  You asked the Plan to reduce the cost share for the regadenoson injection and the myocardial perfusion 
imaging. You say that you have been over charged. The Plan denied your request. The Plan says that this cost 
sharing was charged correctly. 
 
We decided that the Plan has to waive the coinsurance for the injection.  
 
You have been asked to pay 20% coinsurance for the injection. According to Medicare, a regadenoson 
injection (J2785) is considered a packaged code and is not separately payable. The code is also excluded from 
the physician's fee schedule. Therefore, we decided that the Plan has to waive the coinsurance for the injection 
provided on January 9, 2023.  
 
We also decided that the Plan does not have to reduce the copayment for the myocardial perfusion 
imaging. 
 
You have been asked to pay a $250 copayment for the myocardial perfusion imaging. This item/service falls 
within the outpatient diagnostic testing and therapeutic supplies benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to reduce the copayment for the myocardial perfusion imaging provided on January 9, 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: Unfavorable

 
We decided that the Plan does not have to pay for the over-the-counter (OTC) supplements purchased from 
April 3, 2022, to December 29, 2022. 
 
You asked the Plan to pay for the OTC supplements. You say that the OTC supplements you purchased should 
be covered by your benefits, as they are the part of your naturopathic treatment. The Plan denied your request. 
The Plan says the Plan does not offer a supplemental benefit for OTC items. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the 
supplements you purchased are OTC items. Therefore, we decided that the Plan does not have to pay for the 
over-the-counter (OTC) supplements purchased from April 3, 2022, to December 29, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J3490 billed for December 23, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says payment is included in the global surgical package. 
 
The Plan must follow Medicare rules. The rules say that intra-operative services are included in the global 
surgical package.  
 
We looked at the file and Medicare rules. Procedure code J3490 was related to and billed on the same day as minor surgical procedure 64493. Payment for code J3490 is included in the global surgical package for code 
64493. Therefore, we decided that the Plan does not have to pay for procedure code J3490 billed for December 
23, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve parathyroid planar imaging (including subtraction, when 
performed); with tomographic (SPECT) (78071). 
 
You asked the Plan to pre-approve parathyroid planar imaging (including subtraction, when performed); with 
tomographic (SPECT). 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 parathyroid planar imaging (including 
subtraction, when performed); with tomographic (SPECT). Our reviewer says that the requested items/services 
are not considered medically reasonable and necessary in this case. Our physician reviewer found the review 
indicates that the enrollee has a history of parathyroid hormone elevation. Provider's office note indicates there 
is a history of hypercalcemia, although a laboratory value was not received. Physical examination of the neck is 
unremarkable. There is no mention of this test being ordered for preoperative planning purposes, or of a referral 
to surgery. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of parathyroid planar imaging (including subtraction, when performed); with 
tomographic (SPECT) have not been met. Therefore, we decided that the Plan does not have to pre-approve 
parathyroid planar imaging (including subtraction, when performed); with tomographic (SPECT) (78071).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve correction, hallux valgus (bunionectomy), with sesamoidectomy, 
when performed; with first metatarsal and medial cuneiform joint arthrodesis, any method and osteotomy, 
shortening, angular or rotational correction; proximal phalanx, first toe. 
 
You asked the Plan to pre-approve correction, hallux valgus (bunionectomy) and osteotomy. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says that the requested services are not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve correction, hallux valgus 
(bunionectomy) and osteotomy. Our reviewer says that the requested items/services are considered medically 
reasonable and necessary in this case. Our physician reviewer found the enrollee is suffering with a painful 
bunion deformity right and left side. During a medical visit dated May 1, 2023, the enrollee presented to the 
physician for follow-up evaluation of acquired left hallux valgus. Moderate aching, sharp, and worsening pain 
is noted to the left first metatarsal and right first metatarsal. Aggravating factors include walking, weight-
bearing, shoe pressure, range of motion with catching/locking, popping/clicking, and grinding. The medical 
documentation supports that this enrollee is suffering with a painful bunion deformity left side. X-rays reveal 
hallux valgus deformity. Physical examination reveals lateral deviation of the left hallux with pain to the first 
metatarsal phalangeal joint left side. Standard of care treatment for bunions that have not responded to 
conservative care include surgical intervention. After reviewing the medical records, enrollees physical 
examination, and the x-ray results, the requested hallux valgus correction is found medically reasonable and 
necessary for this 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 correction, hallux valgus (bunionectomy) and osteotomy have been met. 
Therefore, we decided that the Plan has to pre-approve correction, hallux valgus (bunionectomy), with 
sesamoidectomy, when performed; with first metatarsal and medial cuneiform joint arthrodesis, any method 
and osteotomy, shortening, angular or rotational correction; proximal phalanx, first toe.  
 
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 pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee was approved for a 
right total shoulder arthroplasty and right long tendon tenodesis and will need inpatient admission after surgery. 
The Plan denied your request. The Plan says there is no documentation provided to support the expectation the 
enrollee will require a greater than 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the enrollee is approved for a right total shoulder arthroplasty and right 
long tendon tenodesis. The record does not document that the treating physician has a reasonable expectation of 
a length of stay spanning 2 or more midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided from January 15, 2023, 
through January 17, 2023. 
 
You asked the Plan to pay for self- administered drugs. You say that you were admitted to the emergency room 
due to COVID-19. The Plan denied your request. The Plan says self-administered drugs do not fall under 
Medicare Part B coverage. 
 
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 pay for self-administered drugs provided 
from January 15, 2023, through January 17, 2023.  
 
Benefits for self- administered drugs 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance code A0429-RW billed for date of service July 
18, 2022. 
 
You asked the Plan to pay for the billed services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the service was not billed with a valid modifier. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that modifier -RW is not a valid ambulance transportation modifier combination. Furthermore, the 
Centers for Medicare and Medicaid Services (CMS) emergency triage, treat, and transport (ET3) model applies 
only to the traditional Medicare fee-for-service program and does not apply to Medicare Advantage plans. 
Based on this information, we decided that Medicare rules for coverage of the billed services have not been 
met. Therefore, we decided that the Plan does not have to pay for ambulance code A0429-RW billed for date of 
service July 18, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the 
Plan's 48-trip limit. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you need transportation to 
dialysis appointments. The Plan denied your request. The Plan says you have exhausted your transportation 
benefit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the Plan's 
48-trip limit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crown - porcelain fused to high noble metal 
(D6750) Tooth #10, 11 and 12. 
 
You asked the Plan to pre-approve the dental services. You say that you the requested services because you 
have no front teeth which is causing health issues. 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. This benefit includes the 
requested retainer crown - porcelain fused to high noble metal but is limited to four units of fixed dentures per 
year, covered one per tooth per life. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you have been pre-approved for retainer crown - porcelain fused to high noble metal (D6750) Tooth #6 
and pontic - porcelain fused to high noble metal (D6240) Tooth #7, 8 and 9. Although these are two different 
services, they fall within the same category in your Evidence of Coverage and are subject to the same 
frequency limitations. Therefore, these benefits have been exhausted as of the authorization dates of February 
17, 2023, to May 18, 2023. Therefore, we decided that the Plan does not have to pre-approve retainer crown - 
porcelain fused to high noble metal (D6750) Tooth #10, 11 and 12.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the pembrolizumab injection and the 
cyclophosphamide injection provided on July 21, 2022. 
 
You asked the Plan to waive the coinsurance for the pembrolizumab injection and the cyclophosphamide 
injection. You say that you cannot afford to pay this amount per visit for chemotherapy treatment. 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 your OOP maximum is  
$7,550. Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B 
prescription drugs.  
 You have been asked to pay $5,545.20 ($27,726 x 20% = $5,545.20) for the pembrolizumab injection. This 
item/service falls within the Medicare Part B prescription drugs benefit category. You have also been asked to 
pay $68.97 for the cyclophosphamide injection. This is less than the standard amount because you had satisfied 
your out-of-pocket maximum with this service. This item/service falls within the Medicare Part B prescription 
drugs benefit category. The total you owe is $5,614.17 ($5,545.20 + $68.97 = $5,614.17). 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 the pembrolizumab injection and the cyclophosphamide injection 
provided on July 21, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 73030 and 72040 billed for date of service 
December 8, 2022. 
 
You asked the Plan to pay for the billed services. You say that the codes are covered by the fee schedule. The 
Plan denied your request. The Plan says the codes area not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We find that CPT code 73030 and 72040 both have a status indicator of Q1. These codes are not separately 
payable when billed with a code that has a status indicator of V, such as code 99284. 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 73030 and 72040 billed for date of service December 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction provided on January 11, 2022. 
 
You asked the Plan to pay for the refraction. You say that you have a referral one file for the enrollee.  The 
Plan denied your request. The Plan says the routine eye benefit has been exhausted. 
 
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. The Plan covers these services when billed as part of the yearly routine eye exam. 
 
We looked at the file and the Plan's rules. Specifically, the enrollee's routine exam benefit has been exhausted 
on November 8, 2022, and a separate fee is not disbursed for a refraction as it is a component of the 
comprehensive exam. Based on this information, we decided that the Plan's rules for coverage of the refraction 
 have not been met. Therefore, we decided that the Plan does not have to pay for the refraction provided on 
January 11, 2022.