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

 
We decided that the Plan does not have to pre-approve surgical placement of implant body: endosteal implant 
tooth #18 (D6010). 
 
You asked the Plan to pre-approve surgical placement of implant body. You say that you would like to get one 
tooth approved for the procedure. The Plan denied your request. The Plan says the documentation does not 
meet the clinical criteria for the surgical placement of implant body; endosteal implant. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers surgical 
placement of implant body 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 surgical placement of implant body. Our reviewer says that the 
requested service is not medically necessary. Our physician reviewer found an implant to replace #18 would 
possibly be considered reasonable and necessary depending on the occlusion that would be achieved by the 
placement of the approved #19. The provided x-rays are not diagnostic and the determination of bone quality 
and potential occlusion make the decision unclear as to the need for the additional #18 unit. Additional 
diagnostic information may support the need for the requested procedure. 
 
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 surgical placement of implant body have not been met. Therefore, we decided 
that the Plan does not have to pre-approve surgical placement of implant body: endosteal implant tooth #18 
(D6010).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 31, 2022. 
 
You asked the Plan to pay for an office visit. You say that the records attached support 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 an office visit provided 
on October 31, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for an out-of-area (OOA) office visit provided on November 24, 2020. 
 
You asked the Plan to pay for the OOA office visit. You say that the visit was for COVID testing and that the 
provider only swabbed her nose. The Plan denied your request. The Plan says that the provider is non-affiliated 
with the Plan. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis, and 
pre-approved care.   
 
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 pay for the OOA office visit. Our reviewer says that 
the criteria for coverage of OOA care have been met, as the services provided were urgent in nature. Our 
physician reviewer found the record shows that you had been exposed to COVID one week prior and had 
respiratory symptoms. You were evaluated and underwent COVID testing. The documentation does not show 
that you could have foreseen requiring the services prior to leaving your service area. The records indicate that 
the care provided was medically necessary and could not have been delayed until you returned to the service 
area. 
 
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 OOA office visit have been met. Therefore, we decided that the Plan has to 
pay for an out-of-area (OOA) office visit provided on November 24, 2020.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and removal of skin lesions provided on 
January 19, 2023. 
 
You asked the Plan to pay for an office visit and removal of skin lesions. You say that this is supported in the 
records. 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 and 
removal of skin lesions provided on January 19, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76770 billed for date of service January 6, 
2023. 
 
You asked the Plan to pay for procedure code 76770. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 76770 is bundled into payment for code 
93975. 
 
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 76770 
is a column II code to column I code 93975. 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 76770 billed for date of service January 6, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency room visit provided on June 20, 2022. 
 
You asked the Plan to pay for an emergency room visit. You say that this is supported in the records. 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 emergency room visit 
provided on June 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric chamber therapy. 
 
You asked the Plan to pre-approve hyperbaric chamber therapy. You say that this is medically necessary. The 
Plan denied your request. The Plan says no information has been received to show the enrollee meets criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
   
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of hyperbaric chamber therapy have been 
met. There are no medical records within the casefile. Without the requested clinical information, we are 
unable to determine if the requested services are medically necessary. Therefore, we decided that the Plan does 
not have to pre-approve hyperbaric chamber therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the x-ray provided on November 14, 2022. 
 
You asked the Plan to reduce the copayment for the x-ray. You say that the services were provided in-network. 
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 in-network Medicare-covered x-rays.  
 
You have been asked to pay a $20 copayment for the x-ray. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the 
copayment for the x-ray provided on November 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the ostomy supplies provided on 
September 24, 2022. 
 
You asked the Plan to waive the coinsurance for the ostomy supplies. You say that you thought this was fully 
covered by the Plan. 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 20% 
coinsurance for durable medical equipment and related supplies. 
 
You have been asked to pay 20% coinsurance for the ostomy supplies. This item/service falls within the 
durable medical equipment and related supplies benefit category. This means that you have been asked to pay 
the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
coinsurance for the ostomy supplies provided on September 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you have been suffering from this 
condition since 1990. You say that your previous doctor authorized the continuous supply of these items. The 
Plan denied your request. The Plan says the requested supplies are not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve injection(s), diagnostic or therapeutic agent, paravertebral facet joint, with image guidance, lumbar or sacral; single level (L3-4) (64493), injection(s), diagnostic or therapeutic agent, paravertebral facet joint, with image guidance, lumbar or sacral; second level (L4-5) (64494) and injection(s), diagnostic or therapeutic agent, paravertebral facet joint, with image guidance, lumbar or sacral; third and any additional level(s) (L5-S1) (64495).

You asked the Plan to pre-approve injections. You say that the injections are medically necessary. The Plan denied your request. The Plan says the requested injections 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 injections. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation you have undergone two sets of diagnostic facet procedures at these sites. There is no documentation on why you are not a candidate for radiofrequency ablation. In addition, the LCD states "One to two levels, either unilateral or bilateral, are allowed per session per spine region. The need for a three or four-level procedure bilaterally may be considered under unique circumstances and with sufficient documentation of medical necessity. The requested procedure is not medically reasonable or necessary according to the coverage criteria established in the LCD.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of injections have not been met. Therefore, we decided that the Plan does not have to pre-approve injection(s), diagnostic or therapeutic agent, paravertebral facet joint, with image guidance, lumbar or sacral; single level (L3-4) (64493), injection(s), diagnostic or therapeutic agent, paravertebral facet joint, with image guidance, lumbar or sacral; second level (L4-5) (64494) and injection(s), diagnostic or therapeutic agent, paravertebral facet joint, with image guidance, lumbar or sacral; third and any additional level(s) (L5-S1) (64495).
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 have a severe vascular 
condition. The Plan denied your request. The Plan says this is not a qualifying wound. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection services billed with code 64484 for date of 
service October 25, 2022. 
 
You asked the Plan to pay for the injection services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services are not payable 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, the CPT Code Manual definition of code 64484 is Injection(s), anesthetic agent(s) and/or steroid; 
transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, each additional level 
(List separately in addition to code for primary procedure). 
 
We find that CPT code 64484 is not supported in the medical record. Specifically, this code has a surgery 
payment indicator of N1- which means this is a packaged service/item. This means no separate payment can be 
made for this code as billed. Based on this information, we decided that Medicare rules for coverage of the 
injection services have not been met. Therefore, we decided that the Plan does not have to pay for the injection 
services billed with code 64484 for date of service October 25, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neurophysiological monitoring rendered on September 21, 
2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says there is no medical necessity, as the neurosurgeon informed the patient prior to surgery 
that there would likely be no recovery of lower extremity neurological function. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee had incomplete spinal cord injury with minimal motor preservation. The physician 
documents that "by undergoing surgical stabilization this will not show any improvement in current 
neurological function." The clinical documentation does not support that the coverage criteria for 
neurophysiological monitoring rendered on 9/21/2022 were met in this case. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for neurophysiological monitoring rendered on September 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mandibular partial denture - cast metal framework with resin 
denture bases (including retentive/clasping materials, rests and teeth) (D5214) provided on November 18, 
2022. 
 
You asked the Plan to pay for dental services. You say that that you were told prior to the service, it would 
fully covered, but then after the appointment you were told it was not covered. The Plan denied your request. 
The Plan says this service is not covered under your 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. Mandibular partial denture - 
cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5214) 
is not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D5214 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for mandibular 
partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests 
and teeth) (D5214) provided on November 18, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on August 02, 2022. 
 
You asked the Plan to pay for physical therapy. You say that you are appealing this denial. 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 physical therapy 
provided on August 02, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an ambulance ride provided on January 12, 
2023. 
 
You asked the Plan to waive the deductible for an ambulance ride. You say that you are on a fixed income and 
this amount will be very difficult to pay. 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 $750 deductible which applies to ambulance services. You have been 
asked to pay $413.04 towards this deductible. 
 
The item or service you asked the Plan to waive the deductible for falls within the ambulance services benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 
deductible which applies to ambulance services. This cost sharing is a contractual obligation that had not been 
met at the time an ambulance ride was received on January 12, 2023. Therefore, we decided that the Plan does 
not have to waive the deductible for an ambulance ride provided on January 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for debridement of nails provided on December 07, 2022. 
 
You asked the Plan to pay for debridement of nails. You say that the records attached support 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 debridement of nails 
provided on December 07, 2022.