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

 
We decided that the Plan does not have to pay for a comprehensive hearing test provided on November 15, 
2022. 
 
You asked the Plan to pay for a comprehensive hearing test. You say that you were told that this provider was 
in-network. 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 comprehensive hearing 
test provided on November 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bifocal lenses (V2203) provided on November 22, 2022. 
 
You asked the Plan to pay for the bifocal lenses. You say that you cannot afford to pay for this. You also say 
that you were assured this would not cost you a dime. The Plan denied your request. The Plan says this 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 once per calendar year. 
 
We looked at the file and the Plan's rules. The record shows that you received frames and/or lenses on January 
11, 2022, and your eyewear benefit has been exhausted. Based on this information, we decided that the Plan's 
rules for coverage of the bifocal lenses have not been met. Therefore, we decided that the Plan does not have to 
pay for the bifocal lenses (V2203) provided on November 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for palliative (emergency) treatment, minor procedure (D9110) 
provided on February 6, 2023. 
 
You asked the Plan to pay for emergency treatment. You say that this is not a covered service. 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 palliative 
(emergency) treatment, minor procedure (D9110) provided on February 6, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided from November 1, 
2022, to November 21, 2022. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you were supposed to leave on 
November 17, 2022, but was kept longer and not advised of any out-of-pocket expense. 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 $0 
copayment per day for days 1 to 20 and a $188 copayment per day for days 21 to 100 for SNF care.  
 
 You have been asked to pay a $940 copayment for a SNF stay. This item/service falls within the SNF care 
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 a SNF stay provided from 
November 1, 2022, to November 21, 2022.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for home health services provided on May 19, 2022, to June 17, 2022. 
 
You asked the Plan to pay for the home health services. You say that the medical records support the medical 
necessity for the home health care services. The Plan denied your request. The Plan says that the NOA for the 
home health series of care was not submitted until June 17, 2022 under claim ending in 2814, which has a start 
of care/admission date of May 19, 2022. 
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan states the NOA was not submitted until June 17, 2022, 
however they have not substantiated the denial as the NOA was not submitted to us. Therefore, we decided that 
the Plan has to pay for home health services provided on May 19, 2022, to June 17, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on January 11, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. 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 January 11, 2023. 
Therefore, we decided that the Plan does not have to pay for the dental services on January 11, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 73503-LT billed for date of service April 
7, 2022. 
 
You asked the Plan to pay for procedure code(s) 73503-LT. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says this code is included in the facility payment and is 
not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 73503-LT. This means 
there is both a professional and technical component for the CPT code(s). In this case, an appropriate modifier 
to indicate the professional component has not been billed with CPT code(s) 73503-LT. Based on this 
information, we decided that Medicare rules for coverage of procedure code 73503-LT have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code(s) 73503-LT billed for date of 
service April 7, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) of brain without contrast 
material (70450) provided on October 10, 2022. 
 
You asked the Plan to pay for the CT. You say that the correct place of service was billed. The Plan denied 
your request. The Plan says the incorrect place of service was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that when services are furnished in a mobile unit, 
they are often provided to serve an entity for which another Place of Service (POS) code exists.  
 
We looked at the file and Medicare rules. The claim reflects the 2-digit place of service (POS) code 22 for on 
campus-outpatient hospital. The member was registered as an inpatient of a hospital during the time of service. 
The appropriate inpatient POS code must be used. Based on this information, we decided that Medicare rules 
for coverage of the CT have not been met. Therefore, we decided that the Plan does not have to pay for the 
computed tomography (CT) of brain without contrast material (70450) provided on October 10, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xgeva. 
 You asked the Plan to pre-approve Xgeva. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
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 Xgeva. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has a diagnosis of breast cancer. The documentation does not support that the enrollee has 
tried and failed intravenous pamidronate or zoledronic acid. The documentation does not support that 
intravenous pamidronate or zoledronic acid would likely be less effective and/or likely have adverse effects for 
the enrollee. Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Xgeva have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Xgeva.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 94640, 96372, and 93005 for date of service 
December 5, 2022. 
 
You asked the Plan to pay for procedure codes 94640, 96372, and 93005. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 94640, 96372, and 93005 are not supported in the medical record. Specifically, these 
codes have status indicators of Q1. CPT 99291 was billed on the same date of service with a revenue code of 
450 which according to the I/OCE Quarterly Release Files has a status indicator of S. This means codes 
94640, 96372, and 93005 are not separately payable as billed. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 94640, 96372, and 93005 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 94640, 96372, and 93005 for date of service 
December 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bone replacement graft (D7953) provided on January 24, 
2023. 
 
You asked the Plan to pay for bone replacement graft. 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 bone 
replacement graft (D7953) provided on January 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup (D2950) provided on February 10, 2023. 
 
You asked the Plan to pay for core buildup. 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 core 
buildup (D2950) provided on February 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical removal of erupted tooth (D7210), sectioning of a 
bridge or fixed partial denture (D9120), limited oral evaluation (D0140) and intraoral- periapical first 
radiographic images (D0220) provided on September 22, 2022. 
 
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 the oral evaluation and intraoral x-ray are not covered when received by an out-of-
network provider. The Plan also says that the surgical removal of erupted tooth and sectioning of a bridge or 
fixed partial denture are not covered services.  
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 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the surgical removal of 
erupted tooth (D7210), sectioning of a bridge or fixed partial denture (D9120), limited oral evaluation (D0140) 
and intraoral- x-rays (D0220) provided on September 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the OON portable oxygen concentrator. You say that you would like to get a 
lighter oxygen tank that is refurbished. You say that the oxygen tank from the OON provider is 2.8 pounds and 
that your current tank is over 6 pounds. The Plan denied your request. The Plan says they have approved a 
lighter portable oxygen tank with a network provider. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a portable oxygen concentrator to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM), supplies and 
accessories. 
 
You asked the Plan to pre-approve the CGM, supplies, and accessories. The Plan denied your request. The Plan 
says the documentation shows a start of insulin 10 units daily in a sliding scale format and does not meet the 
criteria for approval. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the CGM, supplies, and accessories have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a continuous glucose monitor (CGM), supplies and accessories.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided from January 14, 2023, to 
January 16, 2023. 
 
You asked the Plan to pay for the medication. You say that you were in the hospital and had no control over 
medications. 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 
from January 14, 2023, to January 16, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 
22, 2022. 
 You asked the Plan to pay for procedure code 70450. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 
70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service December 22, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the WATS Oral Brush CDx Biopsy test represented by 
procedure codes 88104, 88305, 88312, and 88361 provided on September 16, 2022. 
 
You asked the Plan to pay for the WATS Oral Brush CDx Biopsy test. You say that the WATS Oral Brush 
CDx Biopsy test provided on September 16, 2022, was medically necessary. The Plan denied your request. The 
Plan says the WATS Oral Brush CDx Biopsy test provided on September 16, 2022, was 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 pay for the WATS Oral Brush CDx Biopsy test. Our 
reviewer says that the WATS Oral Brush CDx Biopsy test provided on September 16, 2022, was not medically 
necessary. Our physician reviewer found based on the medical records provided and review of the current peer-
reviewed medical literature, there is no documentation that support that the WATS Oral Brush CDx Biopsy test 
provided on September 16, 2022, was medically reasonable and necessary for the enrollee in this case as 
defined by Medicare criteria. Provided records in this case and the current literature do not document 
equivalence or superiority of the WATS Oral Brush CDx Biopsy test over standard histopathology for the 
evaluation and management of leukoplakia and oral mucositis of the lateral tongue. 
 
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 WATS Oral Brush CDx Biopsy test have not been met. Therefore, we 
decided that the Plan does not have to pay for the WATS Oral Brush CDx Biopsy test represented by procedure 
codes 88104, 88305, 88312, and 88361 provided on September 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on January 23, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the services 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 the dental 
services on January 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6540 that 
were issued on December 8, 2022. 
 
You asked the Plan to pay for the compression stockings. You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says the service is not a covered benefit. 
 The Plan must follow Medicare rules. The rules say that compression stockings described by code A6540 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression 
stockings identified with code A6540 that were issued on December 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation - established patient (D0120), and 
prophylaxis - adult (D1110) provided on January 30, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were told by a sales representative that your 
current physicians and dentist were within the network so this claim should pay. 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 a periodic oral evaluation - established patient (D0120), and prophylaxis - adult (D1110) provided on 
January 30, 2023.