Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on March 14, 2023. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan. You say that the hospital 
facility advised you would be responsible for a $71.06 copayment and the Plan would pay $35. 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 $275 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $275 copayment for a computed tomography (CT) scan. This item/service falls 
within the outpatient diagnostic test 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 a 
computed tomography (CT) scan provided on March 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction (92015) provided on March 28, 2023. 
 
You asked the Plan to pay for the eye refraction. You say that you would like the denial to be reconsidered 
because this was not an optional, but an entirely necessary, procedure to maintain the health and usage of your 
eyes. The Plan denied your request. The Plan says this is a non-covered service because it is a 
routine/preventive exam, or a diagnostic/screening procedure done in conjunction with a routine/preventive 
exam. 
 
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 this service when it is performed during a routine exam. 
 
 
 
 We looked at the file and the Plan's rules. Specifically, the record shows that you were seen for a diagnosis of 
dry eye syndrome of bilateral lacrimal glands. The eye refraction is not a covered benefit since it was 
performed for a medical reason. Based on this information, we decided that the Plan's rules for coverage of the 
eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for the eye 
refraction (92015) provided on March 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic, prophylactic, or diagnostic injection (specify 
substance or drug); subcutaneous or intramuscular (96372-59 and collection of blood specimen from a 
completely implantable venous access device (36591) provided on January 25, 2023. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not covered as billed. 
 
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 36591 
is a column II code to column I code 99214 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Furthermore, per the 
medication administration report the administration for Pegfilgrastim (Neulasta) was administered via a 
Neulasta Delivery Kit (Onpro Kit) and a more appropriate Current Procedural Terminology (CPT) code is 
supported. Per Local Coverage Article (A59073), providers are instructed to use CPT 96377 for the on-body 
application injector for Neulasta Onpro Kit. Therefore, CPT 96372 will not be reimbursed. Therefore, we 
decided that the Plan does not have to pay for the therapeutic, prophylactic, or diagnostic injection (specify 
substance or drug); subcutaneous or intramuscular (96372-59 and collection of blood specimen from a 
completely implantable venous access device (36591) provided on January 25, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the physical therapy services. 
 
You asked the Plan to pre-approve the physical therapy services. You say that additional 10 Physical Therapy 
visits is medically necessary for the enrollee. The Plan denied your request. The Plan says additional physical 
therapy services are not 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 physical therapy services. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found the enrollee's motor strength and range of motion 
have not significantly changed, and the exercises being performed can be accomplished in the context of a 
home exercise program, additional physical therapy are not medically 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 physical therapy services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the physical therapy services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services with an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the dental services. You say that you have seen this doctor before and would 
like to continue to go there. The Plan denied your request. The Plan says dental services from an out-of-
network provider are not covered by your supplemental benefits.  
 
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 are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve dental 
services with an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatments (97810, 97813) provided from 
March 3, 2023, through March 31, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not payable as the provider 
is not enrolled in the Medicare program.  
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
A review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the acupuncture treatments (97810, 
97813) provided from March 3, 2023, through March 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481 and 87653 billed for date of service 
November 3, 2022. 
 
You asked the Plan to pay for procedure codes 87481 and 87653. You say that you have provided medical 
records to support payment. The Plan denied your request. The Plan says payment for codes 87481 and 87653 
is bundled into payment for code 87801. 
 
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 codes 
87481 and 87653 are column II codes to column I code 87801. 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 codes 87481 and 87653 billed for 
date of service November 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6531. 
 
You asked the Plan to pre-approve the compression stockings. You say that you really need these stockings. 
The Plan denied your request. The Plan says you do not meet criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6531 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. 
Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code 
A6531.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance image (MRI) 
provided on December 19, 2022. 
 
You asked the Plan to waive the copayment for a magnetic resonance image (MRI). You say that you disagree 
with the copayment assessed and request some of your money back due to the distance you were required to 
drive for the test. 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 $275 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $275 copayment for a magnetic resonance image (MRI). This item/service falls 
within the outpatient diagnostic test 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 a 
magnetic resonance image (MRI) provided on December 19, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance image (MRI) 
provided on August 16, 2022. 
 
You asked the Plan to waive the copayment for a magnetic resonance image (MRI). You say that the provider 
did not listen to your health concerns and ordered an unncecessary MRI. 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 $180 
copayment for outpatient hospital services.  
You have been asked to pay a $180 copayment for a magnetic resonance image (MRI). This item/service falls 
within the outpatient hospital 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. The total you owe is $176.32, which is less than the standard copayment for 
advanced imaging services. Therefore, we decided that the Plan does not have to waive the copayment for a 
magnetic resonance image (MRI) provided on August 16, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy visit provided on October 27, 2022, by 
an OON provider.  
 
You asked the Plan to pay for the physical therapy visit. You say that you are appealing the claim payment 
denial. The Plan denied your request. The Plan says the services were provided out-of-network and were not 
approved in advanced. 

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 physical therapy visit provided on October 27, 
2022, by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 45 additional trips. 
 
You asked the Plan to pre-approve additional trips. You say that your doctor wants to extend your physical 
therapy, but you cannot afford to pay $50 one-way. The Plan denied your request. The Plan says you have 
exceeded the allotted number of trips. The Plan also says that non-emergency transportation is only covered for 
certain origins and destinations, and outpatient physical therapy does not meet the criteria.  
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 up to 18 one-way 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 45 additional trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nine (9) months of continued use of a home ventilator 
(E0466). 
 
You asked the Plan to pre-approve continued use of a home ventilator. You say that the enrollee requires a 
home ventilator for pulmonary disorder and not receiving proper care would prevent the enrollee from 
maintaining a maximum breathing function. The Plan denied your request. The Plan says the request for 
continued use of non-invasive ventilator (NIV) is not medically reasonable and necessary. 
 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 continued use of a home ventilator. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the record indicates 
that the enrollee has chronic respiratory failure from chronic obstructive pulmonary disease. The record 
indicates that the enrollee has been treated with a device in the bilevel positive airway pressure (BiPAP) 
average volume-assured pressure support (AVAPS) mode. The provided primary source documentation does 
not contain sufficient detailed information in the medical record to justify the treatment selected. The enrollee 
could be treated with a BiPAP machine with AVAPS capability and failure of such a device has not been 
documented. The plan has indicated coverage for such a device is available upon request. 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 continued use of a home ventilator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve nine (9) months of continued use of a home ventilator (E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontic for tooth #12 (D6245), and a retainer crown for 
teeth # 11, #13 (D6740). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. 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. Therefore, we decided that the Plan does 
not have to pre-approve pontic for tooth #12 (D6245), and a retainer crown for teeth # 11, #13 (D6740).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve open skull for exploration at an outpatient level of care (61304). 
 
You asked the Plan to pre-approve open skull for exploration. You say that the services are necessary. The Plan 
denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 open skull for exploration. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found the record indicates that the enrollee has squamous cell carcinoma of the 
occipital scalp with exposed skull. The record indicates that he previously had resection and has approximately 
50% graft adherence, resulting in the need for a subsequent skin graft for coverage. The record provided 
establishes the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. 
The elements of the coverage criteria are satisfied. The requested service is 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 open skull for exploration have been met. Therefore, we decided that the Plan 
has to pre-approve open skull for exploration at an outpatient level of care (61304).  
 
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 comprehensive oral evaluation (D0150) and complete 
series of x-ray images (D0210) provided on March 17, 2023. 
 
You asked the Plan to pay for the dental services. You say that the providers office is in-network but not all the 
practitioners are in-network, and it was their responsibility to get these procedures done by someone covered 
by your insurance. The Plan denied your request. The Plan says the dental services were received from an out-
of-network provider and are not covered by your supplemental benefits.  
 
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 record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the comprehensive oral evaluation (D0150) and complete series of x-ray images (D0210) provided 
on March 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lateral exostosis (D7471). 
 
You asked the Plan to pre-approve lateral exostosis. You say that this should be covered. The Plan denied your 
request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
lateral exostosis (D7471).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mandibular partial denture (D5214) provided on March 
7, 2023. 
 
You asked the Plan to pay for the dental services. You say that the Plan has approved other services with this 
provider, and this should be covered as well. The Plan denied your request. The Plan says the dental services 
were received from an out-of-network provider and are not covered by your supplemental benefits.  
 
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 record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the mandibular partial denture (D5214) provided on March 7, 2023.