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

 
We decided that the Plan does not have to pre-approve a pontic (D6245) for tooth #4, #9, #11, and #12, and a 
retainer crown (D6740) for tooth #3, #5, #6, #7, #8, #10, and #13. 
 
You asked the Plan to pre-approve the dental services. You say that you need the dental work completed for 
your physical and emotional health. The Plan denied your request. The Plan says there are no favorable 
conditions in the tooth to execute the requested procedures; therefore, the pontics and retainer crowns are 
denied. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the dental 
services when the services are medically necessary and reasonable.  
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the dental services. Our reviewer says 
that the dental services are not reasonable and necessary. Our physician reviewer found that the treatment plan 
is requesting a pontic (D6245) for tooth #4, #9, #11, and #12, and a retainer crown (D6740) for tooth #3, #5, 
#6, #7, #8, #10, and #13. The supplied x-rays indicate the abutment teeth have extensive periodontal 
involvement with notable bone loss. Tooth #3 has more than 75% bone loss on the distal root, #3 has 
approximately 60% bone loss and teeth # 5 through #10 would appear to have approximately 50% bone loss. 
Abutment teeth would generally need to have greater than 50% of the supporting bone remaining in order to 
allow for a stable prosthetic bridge. In this instance the abutment teeth are inadequate to support a long span 
fixed bridge due to the generalized periodontal disease and in particular the severely compromised tooth #3 and 
#13 abutments. 
 
The plan criteria for fixed prosthetics are not met as the requested bridge would not be properly made on the 
compromised abutment teeth as seen on the provided x-rays. There is inadequate bone, particularly on tooth #3 
and #13 units, to properly support the long span bridge, making for a poor long-term prognosis. As the 
procedure cannot be properly applied to this situation, the plan criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a pontic (D6245) for tooth #4, #9, #11, and #12, and a retainer crown (D6740) for 
tooth #3, #5, #6, #7, #8, #10, and #13.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gradient compression stockings provided on April 27, 
2023. 
 
You asked the Plan to pay for the gradient compression stocking. You say that you have never had to pay a 
$250 deductible for compression stockings before. 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 $250 deductible which applies to certain items and services. The Plan 
deductible applies to gradient compression stocking. 
 
  The item or service you asked the Plan to pay for falls within the prosthetic devices and related supplies benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 
deductible which applies to certain items and services. The Plan deductible applies to gradient compression 
stocking. This cost sharing is a contractual obligation that had not been met at the time gradient compression 
stocking was received on April 27, 2023. Therefore, we decided that the Plan does not have to pay for the 
gradient compression stockings provided on April 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dialysis services provided on April 1, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the dialysis services. You say that you could not stop providing this service just 
because of network status. The Plan denied your request. The Plan says the services were not authorized. 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the dialysis services provided on April 1, 2023, by 
an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on May 8, 2023, to May 11, 
2023, billed with evaluation and management (EM) code 99232-GC (x2). 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the level of care is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99232 is Subsequent hospital inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and moderate level of medical decision making. When using total time on the date of the 
encounter for code selection, 35 minutes must be met or exceeded. 
 
We asked our physician to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the practitioner services provided. Our reviewer says that 
documentation does not support the billed code Our reviewer found that the documentation from these dates 
describe the patient with stable vitals, with stable glucose on insulin pump (chronic) requiring minor 
adjustments by the endocrinologist. However, the provided documentation did not sufficiently support a 
moderate level of decision making nor did they include the total time spent during the encounter to help 
support the code, 99232.  
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on May 8, 2023, to May 11, 2023, billed with 
evaluation and management (EM) code 99232-GC (x2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0676) provided on 
October 29, 2021. 
 
You asked the Plan to pay for the pneumatic compression device. You say that the item should be covered. The 
Plan denied your request. The Plan says this is not a covered item. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for the pneumatic compression device (E0676) provided on October 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies provided on April 13, 2023, by an 
OON provider.  
 
You asked the Plan to pay for the wound care supplies. You say that these services do not require authorization. 
The Plan denied your request. The Plan says the services were not authorized. 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the wound care supplies provided on April 13, 
2023, by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on 
December 19, 2022, to January 8, 2023. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with the 
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 $325 
copayment per day for days 1-6 for inpatient hospital care.  
 
You have been asked to pay a $325 copayment per day for days 1-6 for inpatient hospital care. The total 
amount you are being asked to pay is $1,625 ($325 x 5 days = $1,625). This item/service falls within the 
inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient 
hospital care provided on December 19, 2022, to January 8, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift mechanism (E0627). 
 
You asked the Plan to pre-approve a seat lift mechanism. You say that the item is medically necessary. The 
Plan denied your request. The Plan says the item is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section are met. 
 
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 seat lift mechanism. Our reviewer 
says that you do not need this item. Our physician reviewer found the documentation doesnt indicate that you have severe neuromuscular disease or that you are incapable of standing up from a regular armchair or any 
chair in your home. 
 
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 seat lift mechanism have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a seat lift mechanism (E0627).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neuromuscular stimulator provided on June 4, 2023, by 
an out-of-network (OON) provider.  
 
You asked the Plan to pay for the neuromuscular stimulator. You say that the enrollee's diagnosis supports the 
services provided. The Plan denied your request. The Plan says the services were not authorized. 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the neuromuscular stimulator provided on June 4, 
2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87798 billed for date of service August 5, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the tests were medically necessary. The Plan 
denied your request. The Plan says the documentation only supports 8 units were tested. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 In this case, the CPT Code Manual definition of code 87798 is infectious agent detection by nucleic acid (DNA 
or RNA), not otherwise specified; amplified probe technique, each organism. 
 
We find that 13 units of CPT code 87798 is not supported in the medical record. Some of the 13 pathogens 
billed with code 87798 were also billed with their own individual code. The most comprehensive code for the 
provided panel testing was not billed. 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 procedure 
code 87798 billed for date of service August 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory polymerase chain reaction (PCR) panel 
provided on April 19, 2023, and billed with codes 87541 and 87798. 
 
You asked the Plan to pay for the respiratory PCR panel. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a singled panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the respiratory PCR panel have not been met. Therefore, we decided that the Plan does not have to pay for the respiratory polymerase chain reaction 
(PCR) panel provided on April 19, 2023, and billed with codes 87541 and 87798.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Leqembi (J0174). 
 
You asked the Plan to pre-approve Leqembi. You say that the drug is medically necessary. 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 Leqembi. Our reviewer says that the drug is not medically necessary. Our physician reviewer found there is no documentation the enrollee is 
participating in a clinical trial for evidence development. The review has determined that the requested use of 
Leqembi is not FDA-approved for the enrollees diagnosis. Its use is not supported by one of the major drug 
compendia or by clinical research. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Leqembi have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Leqembi (J0174).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the humidifier (E0562), provided on April 17, 2023. 
 
You asked the Plan to pay for the humidifier. You say that the item should be covered. The Plan denied your 
request. The Plan says Original Medicare is responsible for payment. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the humidifier (E0562), provided on April 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes G0480, 80307, and 83789 billed for date of 
service April 21, 2023. 
 
You asked the Plan to pay for the billed services. You say that testing is needed to monitor possible opioid 
abuse. The Plan denied your request. The Plan says the records do not include what specific tests are to be 
performed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that presumptive drug testing, billed with code 80307, is not supported. The records do not show that 
this service was provided. We find that definitive drug testing of 1-7 drug classes (CPT code G0480) is not 
supported. There are insufficient records to show that the definitive drug testing was individualized and ordered 
based on clinical history and risk assessment.  
 
Medicare rules say that providers performing validity testing on urine specimens utilized for drug testing 
should not separately bill the validity testing. We find that the testing described by code 83789 is considered 
specimen validity testing which is not separately payable. 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 procedure codes G0480, 80307, and 83789 billed for date of service April 21, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from December 19, 
2022 to December 30, 2022, by an out-of-network (OON) provider.  
 
  You asked the Plan to pay for the inpatient hospital services. You say that the provider may be OON, but is in-
network with the Plan. The Plan denied your request. The Plan says the services were rendered by a non-
network provider who does not work with the enrollees health plan, and the enrollee self-directed for care. The 
Plan also says the enrollee's primary care provider did not refer for services, an no medical necessity for an 
OON provider, such as an urgent or emergency situation, has been documented 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the inpatient hospital services provided from 
December 19, 2022 to December 30, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient stay provided from February 
21, 2023, to February 26, 2023. 
 
You asked the Plan to waive the copayment for an inpatient stay. You say that the hospital stay could have 
been avoided if the provider would have listened to the enrollee's concerns. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $370 copayment per day, for days 1 to 5 and a $0 copayment per day, for days 6 to 365 for each in-
network stay.  
 The enrollee has been asked to pay a $370 copayment per day, for 1 to 5 of the inpatient stay. The enrollee has 
been asked to pay a total of $1,850 ($370 copayment x 5 days = $1,850). You have not been charged for any 
additional days. This item/service falls within the inpatient hospital care benefit category. This means that the 
enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a 
contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for an inpatient stay provided from February 21, 2023, to February 26, 
2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 You asked the Plan to pre-approve Evenity. You say that the enrollee is non-compliant with medications at 
home, so the required drug Forteo is not an option. You say that its best the enrollee be started on a provider 
administered medication such as Evenity.  The Plan denied your request. The Plan says that the step therapy 
requirements have not been met.  
 
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 Evenity. Our reviewer says that Evenity 
is not medically necessary. Our physician reviewer found that the enrollee has not tried and failed the Plan's 
required drug Forteo. Also, there is no indication that the Plan's required drug would likely be less effective or 
likely have adverse effects for the 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 Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.