Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy provided on October 06, 2022, to 
October 28, 2022. 
 
You asked the Plan to pay for the physical therapy. You say that the service was medically necessary. 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 physical therapy 
provided on October 06, 2022, to October 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing-four or more teeth 
per quadrant (D4341 x 4) and gingival irrigation with a medicinal agent, per quadrant (D4921 x 4). 
 
You asked the Plan to pre-approve these dental services. You say that you are requesting a reconsideration of 
the Plan's denial. The Plan denied your request. The Plan says your benefit for the periodontal scaling and root 
planing services requested has already been exhausted. Additionally, the gingival irrigation services requested 
are not covered.  
 
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 periodontal scaling and root planing services requested in this case was exhausted on 
date of service March 3, 2021. Specifically, periodontal scaling and root planing services are covered once 
every three years, per quadrant. You previously received these services on March 2, 2021 and March 3, 2021, 
less than three years prior, which were paid for by the Plan. Therefore, you have exhausted the allowable 
benefit for these services. Additionally, the gingival irrigation services requested in this case are not a covered 
benefit under the supplemental dental policy. Therefore, we decided that the Plan does not have to pre-approve 
periodontal scaling and root planing-four or more teeth per quadrant (D4341 x 4) and gingival irrigation with a 
medicinal agent, per quadrant (D4921 x 4).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a portable gaseous oxygen system provided on April 19, 
2023. 
 
You asked the Plan to pay for a portable gaseous oxygen system. You say that you could not wait to get a prior 
authorization. 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 portable gaseous 
oxygen system provided on April 19, 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 services are medically necessary. The Plan 
denied your request. The Plan says you do not meet the requirements for approval.  
 
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 your medical complexity does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. You do not require an intensive rehabilitation therapy, and it is 
unclear if you would be able to tolerate the services. There is not a reasonable expectation that you will be able 
to benefit from the intensive rehabilitation program provided in an IRF.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 94761 billed for date of service April 3, 
2023. 
 
You asked the Plan to pay for procedure code 94761. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says procedure code 94761 is considered bundled and not 
separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 94761 has a status indicator of T on the Physician Fee Schedule. This means that 
procedure code 94761 is not separately payable if any other services payable under the physician fee schedule 
are billed on the same date by the same provider. The Plan has documented that it has paid for another service 
billed on the same date by the same provider. Based on this information, we decided that Medicare rules for 
coverage of procedure code 94761 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 94761 billed for date of service April 3, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from September 25, 2023, 
through September 28, 2023. 
 
You asked the Plan to pre-approve inpatient psychiatric care from September 25, 2023, through September 28, 
2023. You say that the services at issue were medically necessary. The Plan denied your request. The Plan says 
the services at issue were not medically necessary. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from 
September 25, 2023, through September 28, 2023. Our reviewer says that the enrollee does not meet the criteria 
for treatment in an acute inpatient mental health treatment. Our physician reviewer found the enrollee did not 
require inpatient mental health treatment as she was not a danger to herself or others and did not have any 
delusions, auditory or visual hallucinations. It did not appear that active treatment was taking place. It did not 
appear that the services for the dates in question were reasonably expected or medically necessary to improve 
the enrollees condition or for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from September 25, 2023, through September 28, 
2023, have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient 
psychiatric care from September 25, 2023, through September 28, 2023.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the office visit and pulmonary function 
test provided from January 25, 2023, to February 13, 2023. 
 
You asked the Plan to waive the copayments for the office visit and pulmonary function test. You say that you 
had met your out-of-pocket maximum before these services were received. 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 $35 
copayment for specialist office visits. Your contract with the Plan also clearly says that you must pay a $10 
copayment for non-radiological diagnostic tests. 
 
The record shows your maximum out-of-pocket amount was not exceeded. You have been asked to pay a $35 
copayment for the office visit. This item/service falls within the physician/practitioner services benefit 
category. You have also been asked to pay a $10 copayment for the pulmonary function test. This item/service 
falls within the outpatient diagnostic tests and therapeutic services benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayments for the office visit and pulmonary function test provided from January 25, 2023, to 
February 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an abutment supported to crown (D6059) for tooth #30. 
 
You asked the Plan to pre-approve the dental service. You say that you are appealing the denied dental 
services. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because the abutment supported to crown is not covered by the Plan. 

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, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
abutment supported to crown (D6059) for tooth #30.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Medtronic Infuse BMP allograft (20930). 
 
You asked the Plan to pre-approve a Medtronic Infuse BMP allograft. You say that this is medically necessary. 
The Plan denied your request. The Plan says the clinical value and effectiveness of the Medtronic Infuse BMP 
Allograft in the setting of posterior cervical spine fusion surgery has not been demonstrated in the peer-
reviewed literature. 
 
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 a Medtronic Infuse BMP allograft. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found BMP is not approved for use in the posterior cervical spine. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Medtronic Infuse BMP allograft have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Medtronic Infuse BMP allograft (20930).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says an 
LTACH admission is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the documentation does not support that the enrollee requires services at the 
LTACH that are not available at the acute care hospital where they are currently receiving care. Therefore, the 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service provided on May 15, 2023. 
 
You asked the Plan to pay for the laboratory service. 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 laboratory service 
provided on May 15, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L5 kyphoplasty (22515). 
 
You asked the Plan to pre-approve L5 kyphoplasty. You say that this is medically necessary. The Plan denied 
your request. The Plan says medical necessity coverage criteria are not met as the pain is multifactorial with 
multilevel disc disease in the lumbar spine. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be covered when specific criteria are 
met. 
 
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 L5 kyphoplasty. Our reviewer says that 
the enrollee does not meet criteria for coverage. Our physician reviewer found detailed documentation is not 
evident regarding a progression of the body height loss, greater than 25% vertebral body height loss, kyphotic 
deformity, or a severe impact on daily activities. Moreover, there is magnetic resonance imaging corroboration 
of other plausible causes of pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L5 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve L5 kyphoplasty (22515).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy (77523). 
 
You asked the Plan to pre-approve proton beam radiation therapy. 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 proton beam radiation therapy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found routine use of proton therapy for breast cancer is not an accepted standard 
of care. While proton therapy can be used (and is often used for select patients with unique anatomic 
considerations) the case file does not provide a plausible rationale for the need of proton therapy over 
conventional radiation and/or intensity-modulated radiation therapy in this 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 proton beam radiation therapy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve proton beam radiation therapy (77523).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for Medicare Part B Prescription Drugs, 
outpatient diagnostic test/X-ray services/Medicare-covered radiological diagnostic services and podiatry 
services provided on May 3, 2023, to May 10, 2023. 
 You asked the Plan to waive the cost share for Medicare Part B Prescription Drugs, outpatient diagnostic test 
and podiatry services. You say that you disagree with the cost share. 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% 
coinsurance for Medicare Part B Prescription Drugs a $15 copayment for outpatient diagnostic test/X-ray 
services a $110 copayment for outpatient diagnostic test/Medicare-covered radiological diagnostic services and 
a $35 copayment for podiatry services.  
 
You have been asked to pay a 20% coinsurance for Medicare Part B Prescription Drugs a $15 copayment for 
outpatient diagnostic test a $110 copayment for outpatient diagnostic test and a $35 copayment for podiatry 
services. The total allowed amount for the prescription drugs is $.52. You are being asked to pay $.10 ($.52 x 
20% = $.10). The total amount outpatient diagnostic tests a $110 copayment. However, you are only being 
asked to pay $69.98 copayment which is less than the required amount. You are being asked to pay a $35 
copayment for one date of service also, a $28.05 copayment and a $6.95 copayment which is less than the 
required amount. The total amount you are being asked to pay is $155.08 ($15 + $.10 + $69.98 + $ 35 $28.05 + 
$6.95 = $155.08). This item/service falls within the Medicare Part B Prescription Drugs, outpatient diagnostic 
test/X-ray services/Medicare-covered radiological diagnostic services and podiatry services benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the cost share for Medicare Part B Prescription Drugs, outpatient diagnostic 
test/X-ray services/Medicare-covered radiological diagnostic services and podiatry services provided on May 
3, 2023, to May 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network eye visit provided on March 
23, 2023. 
 
You asked the Plan to waive the copayment for an in-network eye visit. You say that you have chronic eye 
issues which cause you to visit the eye clinic more frequently. This should be covered. 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 $25 
copayment for Physician/Practitioner services, including doctorsoffice visits. 
 
You have been asked to pay a $25 copayment for an in-network eye visit. This item/service falls within the 
Physician/Practitioner services, including doctorsoffice visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for an in-network eye visit provided on March 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cxbladder detect test provided on February 21, 2023. 
 
You asked the Plan to pay for a cxbladder detect test. You say that this service was medically necessary. 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 cxbladder detect test 
provided on February 21, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve T11 kyphoplasty (22513). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says medical necessity coverage criteria is not met as the pain is multifactorial with 
multilevel disc disease. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that detailed documentation is not evident regarding the worsening of pain. Additionally, there is no 
documentation of a progression of the body height loss, kyphotic deformity, or a severe impact on daily 
activities. Moreover, there is magnetic resonance imaging (MRI) corroboration of other plausible causes of 
pain. Therefore, the enrollee does not meet the criteria for coverage. 
 
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 pre-approve T11 kyphoplasty (22513).