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

 
We decided that the Plan does not have to pay for the physical therapy services provided on June 06, 2022, to 
October 08, 2022. 
 
You asked the Plan to pay for the physical therapy services. You say that you did not know about the itemized 
bill. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the physical therapy 
services provided on June 06, 2022, to October 08, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Qutenza patches. 
 
You asked the Plan to pre-approve Qutenza patches. You say that you feel like Qutenza should be approved 
due to you current medical condition and the level of pain you are experiencing. The Plan denied your request. 
The Plan says the enrollee's condition does not meet the criteria for medical necessity for Qutenza patches. 
 
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 Qutenza patches. Our reviewer says 
that the requested drug, Qutenza, is not medically reasonable and necessary. Our physician reviewer found the 
off-label use of the Qutenza patch for your diagnosis 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 Qutenza patches have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Qutenza patches.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for frames, progressive lenses, polycarbonate lenses, anti-
reflective coating, a routine eye examination, and a determination of refractive state provided on January 18, 
2023. 
 
You asked the Plan to pay more for frames, progressive lenses, polycarbonate lenses, anti-reflective coating, a 
routine eye examination, and a determination of refractive state. You say that you were sent a paper from the 
Plan stating the provider has agreed that they will honor the amounts listed. You also say that now the provider 
is refusing to honor those prices. The Plan denied your request. The Plan says you have exceeded your eyewear 
allowance. 
 
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 a $200 allowance for non-Medicare covered eyewear every year. 
 
We looked at the file and the Plan's rules. The Plan rules say that there is a $200 allowance for non-Medicare 
covered eyewear every year. The Plan contract also says that you are responsible for all costs over and above 
the allowance amount. The record shows this benefit was exhausted with this service. Based on this 
information, we decided that the Plan's rules for coverage of frames, progressive lenses, polycarbonate lenses, 
anti-reflective coating, a routine eye examination, and a determination of refractive state have not been met. 
Therefore, we decided that the Plan does not have to pay more for frames, progressive lenses, polycarbonate 
lenses, anti-reflective coating, a routine eye examination, and a determination of refractive state provided on 
January 18, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit provided by an 
in-network provider on March 4, 2023, and the inpatient hospital stay provided by an in-network provider from 
March 14, 2023, to March 16, 2023.  
 
You asked the Plan to waive the copayment for the emergency room visit, and the inpatient hospital stay. You 
say that you should not be charged for the emergency room visit. 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 $90 
copayment for in-network emergency room services, and a $250 copayment per day, days 1 to 4, for in-
network inpatient hospital care. 
 
You have been asked to pay a $90 copayment for the emergency room visit. This item/service falls within the 
emergency care benefit category. You have also been asked to pay a $500 copayment for the inpatient hospital 
stay ($250 copayment x 2 days = $500). 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 the emergency room visit provided by an in-
network provider on March 4, 2023, and the inpatient hospital stay provided by an in-network provider from 
March 14, 2023, to March 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a porcelain pontic (D6241) and a retainer crown (D6751) 
provided on June 22, 2022. 
 
You asked the Plan to pay for a porcelain pontic (D6241) and a retainer crown (D6751). You say that there was 
a change in the type of bridge and the material, so the case was never paid.  The Plan denied your request. The 
Plan says these services require prior authorization. 
 
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 a porcelain 
pontic (D6241) and a retainer crown (D6751) when the services are medically necessary and reasonable.  
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a porcelain pontic (D6241) and a retainer crown (D6751) have not been met. Therefore, we 
decided that the Plan does not have to pay for a porcelain pontic (D6241) and a retainer crown (D6751) 
provided on June 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on December 09, 2022. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration for the services 
provided. 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 lab testing provided on 
December 09, 2022.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve physical therapy (PT) services. 
 
You asked the Plan to pre-approve the therapy services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says that the requested services are not medically reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that the requested therapy services are considered medically reasonable and necessary based on Medicare 
guidelines. Our physician reviewer found the requested physical therapy is generally accepted as a specific and 
effective therapy for low back and shoulder pain as well as weakness and gait instability. While he can perform 
strengthening exercises in the context of a home exercise program, he requires the services of a skilled physical 
therapist given his continued gait instability, lack of coordination and degree of fall risk. He would benefit from 
the additional physical therapy to address this and completely transition to an independent exercise program. 
 
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 therapy services have been met. Therefore, we decided that the Plan has to 
pre-approve physical therapy (PT) services.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cequa. 
 
You asked the Plan to pre-approve the medication. You say that this is a continuation of care because the 
enrollee has showed improvement with this medication. 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 is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Cequa.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 3, 
2023. 
 You asked the Plan to pay for procedure code 70450. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 70450 is bundled into payment for code 70496. 
 
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 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral periapical additional radiographic image 
(D0230) for tooth #21 provided on May 20, 2023. 
 
You asked the Plan to pay for the dental service. You say that you would like the claim paid because the code 
has never been used. 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 the Plan paid for a intraoral periapical additional radiographic image (D0230) for tooth #24 on May 20, 
2023; therefore, your benefit for the requested item or service was exhausted on the date of service of May 20, 
2023. Therefore, we decided that the Plan does not have to pay for the intraoral periapical additional 
radiographic image (D0230) for tooth #21 provided on May 20, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76376 for date of service November 12, 
2022. 
 
You asked the Plan to pay for procedure code 76376. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are 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 76376 is 3D rendering with interpretation and reporting 
of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image 
postprocessing under concurrent supervision; not requiring image postprocessing on an independent 
workstation. 
 We find that CPT code 76376 is not supported in the medical record. Specifically, the documentation does not 
support the 3D rendering of the study. Based on this information, we decided that Medicare rules for coverage 
of procedure code 76376 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76376 for date of service November 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete maxillary denture (D5110) and a partial 
mandibular denture (D5212). 
 
You asked the Plan to pre-approve complete maxillary denture (D5110) and a partial mandibular denture 
(D5212). You say that you are appealing with supporting records. The Plan denied your request. The Plan says 
they denied these services because they arent covered. 
 
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 
complete maxillary denture (D5110) and a partial mandibular denture (D5212).
Appeal type: Lab
Decision: Unfavorable

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

 
We decided that the Plan does not have to pre-approve treatment with Zilretta (J3304). 
 You asked the Plan to pre-approve Zilretta. You say that Zilretta is a medical necessity for the enrollee. The 
Plan denied your request. The Plan says step therapy rules for coverage of Zilretta 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 Zilretta. Our reviewer says that 
treatment with Zilretta is not medically reasonable and necessary in this case. Our physician reviewer found 
that the Plan requires a trial of drugs triamcinolone, methylprednisolone, betamethasone or dexamethasone 
before they will approve the requested drug, Zilretta. Based on the medical records provided, there is no 
indication that the enrollee has tried and failed the required drugs. Based on the medical records provided and 
the Medicare-approved major drug compendia, there is no indication that all of the Plan's required drugs would 
likely be less effective and/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 Zilretta have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Zilretta (J3304).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on May 9, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that after you 
were evaluated it was determined that you did not have any broken bones. You also say that you did not request 
to be taken to the hospital because you did not have any serious injuries. The Plan denied your request. The 
Plan says these services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 9, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on May 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup (D2950) provided on May 15, 2023. 
 
You asked the Plan to pre-approve core buildup (D2950). You say that this should be covered since the 
providers office told you it was going to be. The Plan denied your request. The Plan says this service 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 core 
buildup (D2950) provided on May 15, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance provided on March 12, 2023. 
 
You asked the Plan to waive the copayment for ambulance. You say that you want to appeal the amount being 
charged. 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 ambulance services. 
 
You have been asked to pay a $20 copayment for ambulance. This item/service falls within the ambulance 
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 ambulance provided on 
March 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided on April 3, 2023. 
 
You asked the Plan to pay more for the dental services. You say that this should be covered. 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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 dental services provided on April 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing (D4341) provided on 
June 2, 2023. 
 
You asked the Plan to pay for the dental services. You say that you needed this specific service because you 
have deep pockets and food particles have a tendency to get stuck in them. The Plan denied your request. The 
Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 30, 2022, and 
May 11, 2022. Therefore, we decided that the Plan does not have to pay for periodontal scaling and root 
planing (D4341) provided on June 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI).  
 
You asked the Plan to pre-approve SSBCI benefits. You say that you have the chic qualifying conditions that 
should approve you for the benefit. The Plan denied your request. The Plan says the criteria for eligibility have 
not been met.  
 
  The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).