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

 
We decided that the Plan does not have to pay for a detailed and extensive oral evaluation (D0160) provided on 
July 5, 2023. 
 
You asked the Plan to pay for the dental service. You say that you were referred to the surgeon and it is not a 
dental claim. The Plan denied your request. The Plan says your annual dental maximum benefit for the year 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 the Plan paid $129 for dental services on January 18, 2023. On February 8, 2023, the Plan paid $1,371 
for dental services. On April 5, 2023, the Plan paid $500 for dental services. For the year of 2023 the Plan paid 
$2,000 ($129 paid + $1,371 paid + $500 paid) for dental services; therefore, your annual dental maximum 
benefit for the year of 2023 was exhausted on the date of service of April 5, 2023. Therefore, we decided that 
the Plan does not have to pay for a detailed and extensive oral evaluation (D0160) provided on July 5, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation miles. 
 
You asked the Plan to pre-approve the additional miles. You say that you need the additional miles for a 
magnetic resonance imaging (MRI) appointment and you do not trust your vision to drive to your appointment. 
The Plan denied your request. The Plan says the requested transportation in each direction has gone over the 
mileage limit set in the agreement for routine transportation.  
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 50 miles one-way per trip.  
 
We looked at your request, the records in the case file, and the rules. You are requesting a trip of 52.8 miles. 
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 routine 
transportation miles.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 01, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on August 01, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 You asked the Plan to pre-approve Botox. The Plan denied your request. The Plan says the enrollee has not 
tried a preferred drug. 
 
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 Botox. Our physician reviewer found 
that the enrollee has blepharospasm. The requested medication is a new start. The Plan requires a trial of 
Xeomin before they will approve the requested drug. The provided records do not indicate that the enrollee has 
tried and failed the Plan's preferred alternative. The record does not indicate that the enrollee has a 
contraindication to or would have an adverse effect from the Plan's preferred alternative. The elements of the 
coverage criteria are not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 01, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on August 01, 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 SNF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria for the SNF admission. 
 
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 not 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/or 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a grab bar. 
 
You asked the Plan to pre-approve a grab bar. You say that the item is medically necessary. The Plan denied 
your request. The Plan says this item is not primarily medical in nature. 
 
The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because 
they are not primarily medical in nature.  
 
While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a grab bar.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve rebase complete maxillary denture (D5710), reline 
complete maxillary denture (direct), reline complete maxillary denture (direct) (D5730), reline complete 
mandibular denture (direct) (D5731), reline complete maxillary denture (indirect) (D5750), and reline complete 
mandibular denture (indirect) (D5751). 
 
You asked the Plan to pre-approve the dental services. You say that you would like to have your dentures 
realigned so that you can eat properly. The Plan denied your request. The Plan says coverage is provided for 
only those items and services specifically listed in your Plan contract. 
 
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 services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve rebase 
complete maxillary denture (D5710), reline complete maxillary denture (direct), reline complete maxillary 
denture (direct) (D5730), reline complete mandibular denture (direct) (D5731), reline complete maxillary 
denture (indirect) (D5750), and reline complete mandibular denture (indirect) (D5751).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paramedic intercept services provided on January 13, 
2023. 
 You asked the Plan to pay for the paramedic intercept services. You say that you did not realize the bill was for 
paramedic intercept services and are requesting payment by the insurance. The Plan denied your request. The 
Plan says your coverage does not provide for this ambulance service.  
 
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. 
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as 
defined above. It is noted that the only State in which these criteria are met is New York. 
 
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural 
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the 
paramedic intercept services provided on January 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedures (64628,64629). 
 
You asked the Plan to pre-approve the intracept procedures. The Plan denied your request. The Plan says the 
intracept procedures are 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 the intracept procedures. Our reviewer 
says that the intracept procedures are not medically necessary. Our physician reviewer found that there is no 
magnetic resonance imaging (MRI) showing only modic changes without facet degenerative disease or 
stenosis, and the cause of pain is not clear. Therefore, the request is 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 the intracept procedures have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the intracept procedures (64628,64629).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan of the heart (75571) and a CTA scan of the 
heart with 3D imaging (75574).  
 
You asked the Plan to pre-approve a CT scan of the heart (75571) and a CTA scan of the heart with 3D 
imaging (75574). You say that the enrollee is unable to do a treadmill test due to having polio in one of their 
legs which is much shorter than the other. The Plan denied your request. The Plan says a CT scan of the heart 
(75571) and a CTA scan of the heart with 3D imaging (75574) are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CT scan of the heart (75571) and a 
CTA scan of the heart with 3D imaging (75574). Our reviewer says that a CT scan of the heart (75571) and a 
CTA scan of the heart with 3D imaging (75574) are not medically necessary. Our physician reviewer found 
that the enrollee has no chest pains. Also, the echocardiography showed normal left ventricular function. 
Therefore, the requested imaging is not medically reasonable and necessary in the enrollee's clinical 
management.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CT scan of the heart (75571) and a CTA scan of the heart with 3D imaging 
(75574) have not been met. Therefore, we decided that the Plan does not have to pre-approve a CT scan of the 
heart (75571) and a CTA scan of the heart with 3D imaging (75574).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab tests (87801 and 87150) provided on November 28, 
2022. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says there are no lab results to support these codes. 
 
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 87801 is infectious agent detection by nucleic acid, 
multiple organisms; amplified probe technique. The CPT Code Manual definition of code 87150 is culture, 
typing; identification by nucleic acid probe, amplified probe technique, per culture or isolate, each organism probed. 
 
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 lab tests. Our reviewer says that these codes do not meet 
criteria for payment. Our reviewer found for code 87801, the Plan approved payment for code 87798. The 
record does not include documentation of procedures reported with 87798 and 87801. Both codes would be 
reported for multiple organisms by amplified probe technique. Procedures reported with 87801 cannot be 
verified. For code 87150, this procedure was not found in the report. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have 
to pay for lab tests (87801 and 87150) provided on November 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diabetic supplies (A4239) provided on April 17, 2023.. 
 
You asked the Plan to pay for the diabetic supplies . You say that the item should be covered. The Plan denied 
your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. Neither the date on 
the packing slip or delivery ticket match the date of service. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not 
have to pay for the diabetic supplies (A4239) provided on April 17, 2023..
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup (D2950). 
 
You asked the Plan to pre-approve core buildup. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is covered but it is not required since tooth #19 was already extracted. 
 
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 service cannot be 
covered. Specifically, core buildup is not required because tooth #19 was already extracted. Therefore, we 
decided that the Plan does not have to pre-approve core buildup (D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 test provided on July 3, 2023. 
 
You asked the Plan to pay for the COVID-19 test. You say that you want to be reimbursed payment. The Plan 
denied your request. The Plan says the item is not covered benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the 
COVID-19 test is an OTC item. Therefore, we decided that the Plan does not have to pay for the COVID-19 
test provided on July 3, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 You asked the Plan to pre-approve Euflexxa. The Plan denied your request. The Plan says the enrollee has not 
tried the preferred drugs.  
 
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 Euflexxa. Our physician reviewer found 
that the enrollee has osteoarthritis of the knee. The requested medication is a new start. The Plan requires a trial 
of Orthovisc or Supartz FX before they will approve the requested drug. The provided records do not indicate 
that the enrollee has tried and failed the Plan's preferred alternative. The record does not indicate that the 
enrollee has a contraindication to or would have an adverse effect from the Plan's preferred alternative. The 
elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia (D9222 and D9223) provided on August 24, 
2023. 
 
You asked the Plan to pay for the dental services. You say that the anesthesia should be covered because it was 
a part of the tooth extraction. The Plan denied your request. The Plan says the denial of payment for these 
services is correct, because the anesthesia is not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
anesthesia (D9222 and D9223) provided on August 24, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent identified with code 
64624. 
 
You asked the Plan to pre-approve destruction by neurolytic agent. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the requested services are 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 destruction by neurolytic agent. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has chronic left knee pain after having had left total knee 
arthroplasty. The enrollee has had two sets of diagnostic genicular nerve blocks. The requested services are 
considered experimental therapy. It is the subject of ongoing clinical trials. 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 destruction by neurolytic agent have not been met. Therefore, we decided that 
the Plan does not have to pre-approve destruction by neurolytic agent identified with code 64624.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the mental health visits provided from 
March 15, 2022, to June 26, 2023. 
 
You asked the Plan to waive the cost share for the mental health visits. You say that you disagree with the cost 
share. 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 $950 deductible which applies to outpatient mental health care. Your 
contract with the Plan also clearly says that you must pay $20 copay for each in-network Medicare-covered 
individual or group therapy visit.   
 
You have been asked to pay a $20 copayment for each mental health visit provided on March 15, 2022, and 
July 8, 2022. This item/service falls within the outpatient mental health 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 also been asked to pay $125 towards your $950 deductible for the mental health visit provided on 
June 26, 2023. The item or service you asked the Plan to waive the cost share for falls within the outpatient 
mental health care benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract 
that there is a $950 deductible which applies to outpatient mental health care. This cost sharing is a contractual 
obligation that had not been met at the time the mental health visits was received on March 15, 2022, to June 
26, 2023. Therefore, we decided that the Plan does not have to waive the cost share for the mental health visits 
provided from March 15, 2022, to June 26, 2023.