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

 
We decided that the Plan does not have to pre-approve computed tomography (CT) calcium scoring of the 
heart. 
 
You asked the Plan to pre-approve CT calcium scoring scan. You say that you are appealing this denial. The 
Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 CT calcium scoring scan. Our reviewer 
says that you do not meet criteria for this tst. Our physician reviewer found coronary CT risk-stratifying is only 
recommended for medium or borderline risk individuals who are not automatically recommended a statin based 
on other clinical information, but with a need to decide whether or not to consider statin therapy. CT is not 
useful or supported by evidence as a statin would already be recommended for you and CT would not add more 
assistance with treatment advice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CT calcium scoring scan have not been met. Therefore, we decided that the 
Plan does not have to pre-approve computed tomography (CT) calcium scoring of the heart.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug services related to end-stage renal disease (ESRD) 
provided on September 2, 2022, to September 28, 2022. 
 
You asked the Plan to pay for the ESRD-related drug services. The Plan denied your request. The Plan says 
Medicare does not separately pay for ESRD-related drug. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD drug services are not separately 
payable.  
 
 Providers should bill the facility directly for drug services as they are considered part of the composite rate. No 
other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for the 
drug services related to end-stage renal disease (ESRD) provided on September 2, 2022, to September 28, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical services from an out-of-network (OON) tertiary 
level of care provider. 
 
You asked the Plan to pre-approve the medical services from an OON tertiary level of care provider. You say 
that you were diagnosed with a rare genetic disease that most doctors don't know anything about. You say that 
the requested OON provider has an entire neuromuscular department that specializes directly in your disease. 
You say that you have nowhere else to go that can provide sufficient care.  The Plan denied your request. The 
Plan says that medically necessary care is available in-network. 
 
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 provider at issue in this case is not a network provider with the Plan. 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 medical services from an OON tertiary level of care provider. Our 
reviewer says that the criteria for OON coverage have not been met.  Our physician reviewer found a tertiary 
level of care is not medically reasonable and necessary. The limited neurological history provided for review 
did not discuss the exact etiology of the enrollee's symptoms. There was no indication of a condition that 
readily necessitated evaluation in a tertiary level of care setting. Such an evaluation at this time would 
otherwise appear to exceed the enrollee's clinical needs for the neurology perspective. The Plan has 
demonstrated that they have at least one provider with sub specialization in neuromuscular disorders, which is 
the same subspecialty that the tertiary provider has.  There is nothing unique about the enrollee's condition that 
would make it medically necessary to see the requested OON provider.  
 
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 medical services from an OON tertiary level of care provider have not been 
met.  
 
The Plan has network providers available who can provide the items/services at issue in this appeal. We found 
no exception that would require the Plan to pre-approve the medical services from an OON tertiary level of 
care provider. Therefore, we decided that the Plan does not have to pre-approve medical services from an out-
of-network (OON) tertiary level of care provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) 
provided on January 14, 2023. 
 
You asked the Plan to pay for ambulance response and treatment, no transport. You say that you did not request 
this service. The Plan denied your request. The Plan says the plan covers ambulance transportation only when 
you are actually transported by ambulance. Since you were not transported by this ambulance, the service is not 
covered under your plan. 
 
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 14, 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 ambulance response and treatment, no transport 
(A0998) provided on January 14, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intrauterine device (IUD) (58300) 
 
You asked the Plan to pay for the intrauterine device (IUD). You say that the service is medically necessary. 
The Plan denied your request. The Plan says this is not a covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that  service such as the insertion of an intrauterine 
device (IUD) is not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the intrauterine device (IUD) have not been met. Therefore, we decided that the Plan does not have 
to pay for the intrauterine device (IUD) (58300)
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99283 provided on December 6, 2022. 
 
You asked the Plan to pay for the billed services. You say that the services should be reimbursed at the in-
network rate.  The Plan denied your request. The Plan says the rules for payment have not been met.  
 
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 was not eligible to provide 
services as a freestanding emergency department during the public health emergency. Therefore, we decided 
that the Plan does not have to pay for procedure code 99283 provided on December 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services provided on February 15, 2023. 
 
You asked the Plan to pay for outpatient hospital services. You say that this was medically necessary and 
should be covered. 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 outpatient hospital 
services provided on February 15, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the medical records provided support the need for an 
IRF admission.  The Plan denied your request. The Plan says the record shows that the enrollee does not meet 
Medicare guidelines for services in an inpatient rehabilitation facility. 
 
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 no acute rehabilitation nursing needs are identified or documented. The document 
does not support necessity for admission to an IRF, as there is no current medical complexity. The complexity 
of the enrollee's nursing, rehabilitation, and medical, needs (combined complexity) do not require an acute 
hospital inpatient rehabilitation stay with an interdisciplinary approach to rehabilitative care. While the enrollee 
may benefit from physical therapy and occupational therapy, the enrollee's rehabilitation needs can be provided 
in a lower intensity and alternate setting such as in a skilled nursing facility. 
 
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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the progressive lens, the anti-reflective coating, and the 
deluxe lens feature provided on January 27, 2023. 
 
You asked the Plan to pay for the progressive lens, the anti-reflective coating, and the deluxe lens feature. You 
say that you were charged $242, and you believed you only had to pay $175.  You say you are requesting to be 
reimbursed the difference of $67 for the progressive lens. The Plan denied your request. The Plan says the 
services are not covered benefits. 
 
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 does not cover these services. 
 
We looked at the file and the Plan's rules. Specifically, the services are not covered benefits. Based on this 
information, we decided that the Plan's rules for coverage of the progressive lens, the anti-reflective coating, 
and the deluxe lens feature have not been met. Therefore, we decided that the Plan does not have to pay for the 
progressive lens, the anti-reflective coating, and the deluxe lens feature provided on January 27, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the robotic surgical system (S2900). 
 
You asked the Plan to pay for the robotic surgical system. You say that the service was medically necessary. 
The Plan denied your request. The Plan says this provider is not enrolled in Medicare. 
 
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. 
 
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 robotic surgical system (S2900).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Diclofenac Sodium. 
 
You asked the Plan to pre-approve the requested 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 pre-approve Diclofenac Sodium.  Benefits for the requested 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for removal of residual tooth roots (D7250), complete 
denture - maxillary (D5110), and immediate mandibular partial denture (D5222) provided on November 5, 
2022. 
 
You asked the Plan to pay more for the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says you are responsible for any charged amount above the Plans cost-sharing amount 
when your services are received from an out-of-network provider.  
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.  
Therefore, we decided that the Plan does not have to pay more for removal of residual tooth roots (D7250), 
complete denture - maxillary (D5110), and immediate mandibular partial denture (D5222) provided on 
November 5, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the eyewear provided on December 7, 2022. 
 
You asked the Plan to pay for the eyewear. You say that the Plan did not apply the $300 benefit towards the 
eyewear.  The Plan denied your request. The Plan says that the benefit has been exhausted. 
 
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 these services up to a $300 allowance. 
 
We looked at the file and the Plan's rules. Specifically, the record shows the Plan only paid $195.01 against the 
allowed amount. This means the benefit had not been exhausted and the Plan should pay the additional 
$104.99. Based on this information, we decided that the Plan's rules for coverage of the eyewear have been 
met. Therefore, we decided that the Plan has to pay for the eyewear provided on December 7, 2022.  
 
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: Favorable

 
We decided that the Plan has to pay for  procedure codes 71250 and 74176 billed for date of service July 6, 
2022. 
 
You asked the Plan to pay for  the billed services. You say that  The Plan denied your request. The Plan says 
that the service does not meet the coverage requirements in the applicable local or national coverage 
determinations.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
In this case, the Plan did not provide the Local Coverage Determination or National Coverage Determination 
that was used in their decision to deny services. The Plan did not offer an explanation to further substantiate 
why the services were not payable as billed. The Plan has not made reasonable and diligent efforts to gather 
and forward to us information regarding their decision to deny your request.  Therefore, we decided that the 
Plan has to pay for  procedure codes 71250 and 74176 billed for date of service July 6, 2022.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CT of the abdomen and pelvis and the MRI scan of leg 
joint without contrast provided on December 1, 2022. 
 
You asked the Plan to pay for the CT abdomen and pelvis and the MRI scan of leg joint without contrast. You 
say that you live on a fixed income and the billed amount is a financial burden. 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 $750 deductible and $120 copayment which applies to other outpatient 
diagnostic tests  radiology. 
 You have been asked to pay a total of $722.66, for the CT abdomen and pelvis and MRI scan of leg joint 
without contrast. 
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
December 1, 2022 CT scan $453.42 $750 deductible $453.42 
December 1, 2022 MRI scan $643.66 $750 deductible $149.24 
December 1, 2022 MRI scan $643.66 $120 copayment $120 
TOTAL:    $722.66 
 
The item or service you asked the Plan to pay for  falls within the other outpatient diagnostic tests  radiology 
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $750 
deductible and $120 copayment which applies to other outpatient diagnostic tests  radiology. This cost sharing 
is a contractual obligation that had not been met at the time of the CT abdomen and pelvis and MRI scan of leg 
joint without contrast that was received on December 1, 2022. Therefore, we decided that the Plan does not 
have to pay for the CT of the abdomen and pelvis and the MRI scan of leg joint without contrast provided on 
December 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99497 billed for date of service April 18, 
2022. 
 You asked the Plan to pay for procedure code 99497. You say that you disagree with the denial and submitted 
medical records for review. The Plan denied your request. The Plan says payment for code 99497 is bundled 
into payment for code 99220. 
 
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 99497 
is a column II code to column I code 99220. 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 99497 billed for date of service April 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99214-24 billed for date of service December 
1, 2022. 
 
You asked the Plan to pay for the billed services. You say that the enrollee developed blurry vision again.  The 
Plan denied your request. The Plan says the code is included in the global surgery procedure. 
 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, CPT code 99214, billed with the -24, was not shown to be an unrelated evaluation and 
management service. 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 code 
99214-24 billed for date of service December 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical assistant during the arthroscopy (29880). 
 
You asked the Plan to pay for the surgical assistant during the arthroscopy. You say that the service was 
medically necessary. The Plan denied your request. The Plan says the record does not show that the provider of 
the surgical assistant service is a physician, physician assistant, 
nurse practitioner, or clinical nurse specialist. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for the surgical assistant during the 
arthroscopy (29880).