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

 
We decided that the Plan does not have to pay for porcelain/ceramic crowns (D2740) provided on January 19, 
2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental 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 
porcelain/ceramic crowns (D2740) provided on January 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the foot orthotics (L3020) and the sales tax 
(S9999) purchased on January 23, 2023. 
 
You asked the Plan to issue 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 these items are not a covered 
benefit.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. Additionally, routine chiropractic services are 
covered by the Plan. 
 
The record shows that the items at issue are not covered by Medicare or the Plan when performed by a 
chiropractor. Therefore, we decided that the Plan does not have to issue reimbursement for the foot orthotics 
(L3020) and the sales tax (S9999) purchased on January 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new patient eye examination (92002) provided on March 
29, 2023. 
 
You asked the Plan to pay for a new patient eye examination (92002). You say that an authorization should be 
on file for the members stay at this facility. 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 a new patient eye 
examination (92002) provided on March 29, 2023.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the cervical spine (72141). 
 
You asked the Plan to pre-approve an MRI of the cervical spine. You say that this is medically necessary. The 
Plan denied your request. The Plan says that this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 an MRI of the cervical spine. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found during the encounter of 
June 12, 2023, the notes indicate a normal neurological exam but there is reference to prior epidural steroid 
injection and prior suboccipital rhizotomy. The requested MRI is to be done prior to a repeat rhizotomy. These 
prior procedures indicate a conservative and minimally invasive therapeutic approach and should satisfy such 
requirements for the requested MRI. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the cervical spine have been met. Therefore, we decided that the Plan 
has to pre-approve magnetic resonance imaging (MRI) of the cervical spine (72141).  
 
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 the computed tomography cerebral perfusion analysis (CTP)  
(0042T). 
 You asked the Plan to pay for the CTP. You say that the service is medically necessary. The Plan denied your 
request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that CTP (using automated post-processing software 
algorithmic analysis) is medically reasonable and necessary in patients with small acute ischemic stroke (AIS) 
caused by unilateral large vessel occlusion (LVO) in the proximal anterior circulation evaluated at stroke 
centers. 
 
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 CTP. Our reviewer says that the service 
is not medically necessary. Our physician reviewer found the enrollee does not have a large or even small 
vessel occlusion. 
 
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 CTP have not been met. Therefore, we decided that the Plan does not have 
to pay for the computed tomography cerebral perfusion analysis (CTP)  (0042T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the water circulating heat pad with pump (E0217) provided 
on November 18, 2022, through December 9, 2022. 
 
You asked the Plan to pay for the water circulating heat pad with pump . You say that the item was medically 
necessary. The Plan denied your request. The Plan says this is not a covered item. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. If code E0215 or E0217 is provided it will be denied as not reasonable and 
necessary.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the water circulating heat pad with pump have not been met. Therefore, we decided that the Plan 
does not have to pay for the water circulating heat pad with pump (E0217) provided on November 18, 2022, 
through December 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675) provided on 
November 18, 2022, through December 9, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the item was medically necessary. 
The Plan denied your request. The Plan says a PCD that provides intermittent limb compression for the purpose 
of prevention of venous thromboembolism is a preventive service. Items that are used for a preventative service 
or function are excluded from coverage 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for the pneumatic compression device (E0675) provided on November 18, 2022, through December 9, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse frames (V2020), trifocal, spherocylinder lenses (V2303), 
and anti-reflective coating (V2750) provided on March 20, 2023. 
 
You asked the Plan to reimburse frames (V2020), trifocal, spherocylinder lenses (V2303), and anti-reflective 
coating (V2750). You say that you did not authorize or tell the attendant that you would like trifocals and the 
lens coating. The Plan denied your request. The Plan says your benefit was exhausted with this service. 
 
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 up to $300 for eyeglasses (lenses and frames) on your benefit plan. 
 
We looked at the file and the Plan's rules. The Plan rules say there is a $300 allowance for eyeglasses (lenses 
and frames) on your benefit plan. The Plan rules also say if the eyewear you purchase costs more than the 
allowance listed for your plan, you pay the difference. The record shows the Plan paid their portion of the 
glasses. The record also shows that you received these services. Based on this information, we decided that the 
Plan's rules for coverage of frames (V2020), trifocal, spherocylinder lenses (V2303), and anti-reflective coating 
(V2750) have not been met. Therefore, we decided that the Plan does not have to reimburse frames (V2020), 
trifocal, spherocylinder lenses (V2303), and anti-reflective coating (V2750) provided on March 20, 2023.  
 
Your complaint about potentially receiving lenses you did not agree to is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new patient eye examination provided on April 04, 2023. 
 
You asked the Plan to pay for a new patient eye examination. You say that an authorization should be on file 
for the members stay at this facility. 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 a new patient eye 
examination provided on April 04, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93971 billed for date of service December 5, 
2022. 
 
You asked the Plan to pay for procedure code 93971. You say that procedure code 93971 was not bundled with 
any other procedure code performed on the same date of service. You say that the medical records should be 
reviewed, and the claim reprocessed for payment. The Plan denied your request. The Plan says payment for 
code 93971 is bundled into payment for code 93970. 
 
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 93971 
is a column II code to column I code 93970. 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 93971 billed for date of service December 5, 
2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after July 
27, 2023. 
 You asked the Plan to pre-approve SNF care after July 27, 2023. You say that the continued admission to a 
SNF is medically necessary. The Plan denied your request. The Plan says the continued admission to a SNF is 
not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care after July 27, 2023. Our 
reviewer says that the requested SNF care is not considered medically reasonable and necessary based on 
Medicare guidelines. Our physician reviewer found the enrollee does not have daily skilled nursing needs that 
require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not 
have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient 
basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care after July 27, 2023, have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continued skilled nursing facility (SNF) care after July 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup (D2950 x1), a crown (D2740 x1) and 
periodontal scaling and root planing (D4341 x1). 
 
You asked the Plan to pre-approve the dental services. You say that you cannot perform your daily activities, 
and you cannot eat and will lose weight. 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 Plan's 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 July 27, 2023 when the Plan authorized 
D2950 x3, D2740 x3 and D4341 x1. Therefore, we decided that the Plan does not have to pre-approve core 
buildup (D2950 x1), a crown (D2740 x1) and periodontal scaling and root planing (D4341 x1).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 37186, 75716-59, 37252, 37253, and 
75625-59 billed for date of service January 27, 2023. 
 
You asked the Plan to pay for the billed services. You say that the documentation supports the codes. The Plan 
denied your request. The Plan says the billed codes cannot be verified. 
 
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 37186 is a column II code to column I code 37227. Code 37186 was 
not billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing 
criteria have not been met. 
 
The CPT Code Manual definition of code 75716 is angiography, extremity, bilateral, radiological supervision 
and interpretation.  Angiograms are included in interventional vascular procedures. The medical records do not 
show that the service billed with the -59 modifier is a distinct procedural service. Based on this information, we 
decided that Medicare rules for coverage of the billed services have not been met. 
 
The CPT Code Manual definition of code 37252 is intravascular ultrasound (noncoronary vessel) during 
diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation; 
initial noncoronary vessel (List separately in addition to code for primary procedure). The CPT Code Manual 
definition of code 37253 is intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or 
therapeutic intervention, including radiological supervision and interpretation; each additional noncoronary 
vessel (List separately in addition to code for primary procedure). The CPT Code Manual definition of code 
75625-59 is aortography, abdominal, by serialography, radiological supervision and interpretation. 
 
We find that CPT codes 37252, 37253, and 75625-59 are not supported in the medical record. Specifically, the 
records do not include these distinct procedures along with their interpretation reports. Based on this 
information, we decided that Medicare rules for coverage of the billed services have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 37186, 75716-59, 37252, 37253, and 75625-
59 billed for date of service January 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

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

 
We decided that the Plan does not have to pre-approve Injectafer. 
 You asked the Plan to pre-approve Injectafer. You say that this is medically necessary. The Plan denied your 
request. The Plan says we don't have a record from your prescriber that shows you've tried one of the preferred 
drugs (Ferrlecit, Infed or Venofer) and it hasn't worked, or that you have medical reasons that prevent you from 
using one of them. 
 
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 Injectafer. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the requested medication is a new start.  The 
provided records do not indicate that the enrollee has tried and failed the plan's preferred step one alternative. 
The record does not indicate that the enrollee has a contraindication to or would have an adverse effect from 
the plan's preferred step one alternative.  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 Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cystourethroscopy, with insertion of temporary prostatic 
implant/stent with fixation/anchor and incisional struts (iTIND procedure) (C9769). 
 
You asked the Plan to pre-approve the iTIND procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is 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 the iTIND procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the use of a temporarily implanted nitinol device (iTind) is considered investigational 
as a treatment of lower urinary tract symptoms due to benign prostatic hyperplasia. Further studies are needed 
to evaluate the durability of iTIND outcomes over a longer follow-up, to better define the indications of this 
approach, and to demonstrate the advantages of second-generation device over the first device. 
 
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 iTIND procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve cystourethroscopy, with insertion of temporary prostatic implant/stent with 
fixation/anchor and incisional struts (iTIND procedure) (C9769).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve five office visits and treatment to be provided by the 
requested out-of-network provider. 
 
You asked the Plan to pre-approve office visits and treatment to be provided by the requested out-of-network 
provider. You say that this provider did your original prostate surgery ten years ago and for the past ten years 
you have seen him twice a year for follow up. The Plan denied your request. The Plan says you are now 
established with local providers and there is no medical necessity for additional visits. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve five office 
visits and treatment to be provided by the requested out-of-network provider.