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

 
We decided that the Plan does not have to pay for lab services (0202U) provided on August 19, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the billed code is not eligible for payment. 
 
The Plan must follow Medicare rules. Medicare rules say that code 0202U is non-covered. 
 
We looked at the file and Medicare rules. The billed code is not covered under Medicare rules. Based on this 
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for lab services (0202U) provided on August 19, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided in the emergency 
department on March 1, 2023. 
 
You asked the Plan to pay for the 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 are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided 
in the emergency department on March 1, 2023.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-transport ambulance services provided on May 8, 
2022. 
 
You asked the Plan to pay for the non-transport ambulance services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says you billed these services with 
an incorrect modifier. 
 
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 8, 2022. 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 non-transport ambulance services provided on 
May 8, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hymovis injections.  
 You asked the Plan to pre-approve the Hymovis injections. You say that it is felt that this should approved.  
The Plan denied your request. The Plan says there is no reason noted that the preferred agents cannot be used.  
 
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 the Hymovis injections. Our reviewer 
says that the requested drug is not considered reasonable and necessary based on step therapy rules.  Our 
physician reviewer found the Plan requires a trial of drug Orthovisc or Supartz FX before they will approve the 
requested drug. In this case, the enrollee has not tried and failed the required drug(s). There is no 
documentation provided indicating that the plan's required drug(s) 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 the Hymovis injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Hymovis injections.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder Detect (0012M) provided January 16, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that you are appealing the denial of coverage for 
CxBladder Detect test for the enrollee. The Plan denied your request. The Plan says the CxBladder panel 
remains unproven at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not have to pay 
for the CxBladder Detect (0012M) provided January 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cataract surgery provided on January 17, 2023, by an 
OON provider.  
 
You asked the Plan to pay for the cataract surgery. You say that you are appealing the denial of this claim. The 
Plan denied your request. The Plan says this service was 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 requested provider in this case is not a network provider with the Plan. 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 cataract surgery provided on January 17, 2023, 
by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-transport ambulance services provided on December 5, 
2022. 
 
You asked the Plan to pay for the non-transport ambulance services. You say that these services were billed 
correctly. The Plan denied your request. The Plan says you billed these services with an incorrect modifier. 
 
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 December 5, 2022. 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 non-transport ambulance services provided on 
December 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (U0005) provided on November 29, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this add-on code is billed without a valid primary code. 
 
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 the lab services is an add-on code and has not been billed with an appropriate primary procedure code. Based on the 
claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have 
to pay for lab services (U0005) provided on November 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the podiatry services provided on December 07, 2022. 
 
You asked the Plan to pay for the podiatry services. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the podiatry services 
provided on December 07, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for splint  extra-coronal; natural teeth or prosthetic crowns 
(D4323) and alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces, per quadrant 
(D7320) provided on June 29, 2022, and November 28, 2022. 
 
You asked the Plan to pay for dental services. You say that you got this plan because you thought these 
services would be covered. The Plan denied your request. The Plan says these services are 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. Splint  extra-coronal; natural 
teeth or prosthetic crowns (D4323) and alveoloplasty not in conjunction with extractions - four or more teeth or 
tooth spaces, per quadrant (D7320) are not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D4323 and D7320 are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for splint 
 extra-coronal; natural teeth or prosthetic crowns (D4323) and alveoloplasty not in conjunction with 
extractions - four or more teeth or tooth spaces, per quadrant (D7320) provided on June 29, 2022, and 
November 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical placement of implant body (D6010) provided on 
March 22, 2023. 
 
You asked the Plan to pay for surgical placement of implant. 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 pay for surgical 
placement of implant body (D6010) provided on March 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue additional reimbursement for the hearing aids (V5259) 
purchased on February 27, 2023. 
 
You asked the Plan to issue additional reimbursement for these items. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says you have 
exhausted the allowable benefit for these items. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case.   
  
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
additional coverage of these items have not been met. Specifically, the Plans contract states that the Plan will 
reimburse you up to $500 once every 36 months towards the cost of hearing aids. The Plan has provided 
coverage in the amount of $500 for the hearing aids purchased in this case. Therefore, we decided that the Plan 
does not have to issue additional reimbursement for the hearing aids (V5259) purchased on February 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on December 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that you thought the provider was in network. 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 dental services provided on December 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete maxillary denture (D5110), and an immediate 
mandibular denture (D5140), provided on February 3, 2023. 
 
You asked the Plan to pay for D5110 and D5140. You say that you have gone 8 years without dentures. The 
Plan denied your request. The Plan says the rendered dentures are not covered 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
complete maxillary denture (D5110), and an immediate mandibular denture (D5140), provided on February 3, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365 and 96366 rendered on February 2, 
2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services 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 the denied codes is: 
 
CPT 96365: 
 
Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour  
CPT 96366: 
 
Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour 
(List separately in addition to code for primary procedure) 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the record states that insulin was 
administered under continuous monitoring and glucose measurement. There is a more specific code to report 
this service. 
 
We looked at this coder'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 procedure codes 96365 and 96366 rendered on February 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 8 vertical x-rays (D0277) provided on February 8, 2023. 
 
You asked the Plan to pay for 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 on date of service February 8, 2023. 
Therefore, we decided that the Plan does not have to pay for 8 vertical x-rays (D0277) provided on February 8, 
2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee was very independent before the 
accident and requires rehabilitation to regain that strength and independence. The Plan denied your request. 
The Plan says the enrollee does not meet the requirements for an IRF admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary care can 
be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vertical bitewings - 7 to 8 radiographic images (D0277) 
provided on February 7, 2023. 
 
You asked the Plan to pay for the vertical bitewings. You say that this is your first dental appointment with this 
provider. You also say that you called the previous provider and they did not have a record of providing 
D0277, 8 vertical x-rays in the last 36 months. The Plan denied your request. The Plan says your benefit for the 
vertical bitewings - 7 to 8 radiographic images 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 vertical bitewings - 7 to 8 radiographic images was exhausted on date of service 
February 7, 2023. Therefore, we decided that the Plan does not have to pay for vertical bitewings - 7 to 8 
radiographic images (D0277) provided on February 7, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve testing of autonomic nervous system function (codes 
95921 and 95923). 
 
You asked the Plan to pre-approve testing of autonomic nervous system function. The Plan denied your 
request. The Plan says testing with ANSAR ANX 3.0 or similar machine is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that testing with ANSAR ANX 3.0 or a similar 
machine is considered investigational for screening and will not be covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of testing of autonomic nervous system function have not been met. Therefore, we decided that the 
Plan does not have to pre-approve testing of autonomic nervous system function (codes 95921 and 95923).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on September 28, 2022. 
 
You asked the Plan to pay for the psychotherapy. You say that the services were medically necessary. The Plan 
denied your request. The Plan says this provider type is not eligible in the Medicare program. 
 
The Plan must follow Medicare rules. Medicare rules say that a Licensed Professional Counselor is not 
eligible to participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Licensed Professional 
Counselor. Medicare says that a Licensed Professional Counselor is not eligible to participate in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for psychotherapy provided on  
September 28, 2022.
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 January 26, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you are 
requesting reconsideration as you cannot afford this. 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 January 26, 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 January 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the workout bicycle (A9270) purchased on February 8, 2023. 
 
  You asked the Plan to pay for the workout bicycle. You say that with COVID-19 you do not feel comfortable 
going to a gym and using equipment other people use. You also say that you purchased the bike to promote 
health. The Plan denied your request. The Plan says workout bicycles are not a covered benefit under your Plan 
and is not applicable for reimbursement under your Wellness Allowance benefit.  
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. However, the 
Plan offers an annual $350 Wellness Allowance for you to use toward specific items and services. A workout 
bicycle is not covered under the Wellness Allowance. Therefore, we decided that the Plan does not have to pay 
for the workout bicycle (A9270) purchased on February 8, 2023.