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

 
We decided that the Plan does not have to pre-approve an endosteal implant (D6010) for tooth #19. 
 
You asked the Plan to pre-approve D6010. You say that this is needed to complete the implant process. The 
Plan denied your request. The Plan says after evaluation of the information there is no evidence to support this 
type of procedure. 
 
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 Plan covers D6010 when 
the services are medically necessary and reasonable.  
 
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 D6010. Our physician reviewer found 
provided records document no enrollee symptoms related to tooth #19; records do not document any informed 
decision making between the dentist and the enrollee indicating the requested procedure is the most appropriate 
treatment for the enrollee's condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of D6010 have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an endosteal implant (D6010) for tooth #19.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visits provided on April 
12, 2023, to April 14, 2023. 
 
You asked the Plan to waive the copayment for specialist office visits. You say that you disagree with the 
copayment. 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 physician/practitioner services/specialist. 
 
You have been asked to pay a $35 copayment for specialist office visits. This item/service falls within the 
physician/practitioner services/specialist 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. The total amount you owe is $70 ($35 x 2 visits = $70). Therefore, we 
decided that the Plan does not have to waive the copayment for specialist office visits provided on April 12, 
2023, to April 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment (DME) 
provided on August 02, 2023. 
 
You asked the Plan to waive the coinsurance for durable medical equipment (DME). You say that you disagree 
with the coinsurance. 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 20% 
coinsurance for durable medical equipment (DME). 
 
You have been asked to pay 20% coinsurance for durable medical equipment (DME). This item/service falls 
within the durable medical equipment (DME) 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 coinsurance 
for durable medical equipment (DME) provided on August 02, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 08, 2023. 
 
You asked the Plan to pay for an office visit. You say that you do not understand why the plan did not pay for 
this service. You needed to see the doctor. 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 an office visit provided 
on August 08, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom ramp (E1399). 
 
You asked the Plan to pre-approve a custom ramp. You say that you cannot get out of your house. You do not 
need a custom ramp; you need an 8-foot ramp. The Plan denied your request. The Plan says a custom ramp is 
not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal is not covered by Medicare or the Plan. Please note that the Plan approved a 
portable ramp for you on September 28, 2023. Therefore, we decided that the Plan does not have to pre-
approve a custom ramp (E1399).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periapical radiographs (D0220/D0230), endodontic therapy 
(D3330), a resin-based composite (D2391), a bitewing (D0270), and a cone beam CT capture (D0360) 
provided on July 17, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay more for these 
services. The Plan denied your request. The Plan says these services have been processed correctly. 
 
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 periapical image was exhausted on date of service June 27, 2023, and your annual dental allowance amount was exhausted on July 17, 2023. This benefit does not include D0360 Therefore, we 
decided that the Plan does not have to pay for periapical radiographs (D0220/D0230), endodontic therapy 
(D3330), a resin-based composite (D2391), a bitewing (D0270), and a cone beam CT capture (D0360) 
provided on July 17, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a kidney ultrasound provided on August 
03, 2023. 
 
You asked the Plan to reduce the copayment for a kidney ultrasound. You say that you were told this was a $40 
copayment, now you are being charged more and you dont know why. 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 $150 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $150 copayment for a kidney ultrasound. This item/service falls within the 
outpatient diagnostic tests and therapeutic services and supplies 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. However, since the allowed amount is less than the 
standard copayment, you only owe $103.58. Therefore, we decided that the Plan does not have to reduce the 
copayment for a kidney ultrasound provided on August 03, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Image Guidance Radiation Therapy (IGRT) (G6001). 
 
You asked the Plan to pre-approve IGRT. You say that you consider the denied imaging service is required to 
confirm if the radiation is working or not. The Plan denied your request. The Plan says there is not enough 
evidence that this type of radiation therapy guidance is needed or effective for your skin cancer. 
 
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 IGRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found usually, IGRT is used when critical structures are abutting or in close proximity to the target 
that is being treated to high doses. This situation does not apply to you for which the target lesion can be seen 
on the skin to assist in daily set up. When treating skin cancers, there is generally not a need for IGRT unless 
deep structures are being treated. Certainly, using ultrasound on a daily basis is not unreasonable to offer but 
not necessary. The device itself is Food and Drug Administration (FDA) approved for use with ultrasound 
though that in and of itself does not mean that daily imaging is necessary but simply that the device was 
designed to incorporate this functionality. Therefore, to bill for daily simple simulations and/or IGRT for a 
technology for which need has not been established by published data or supported by consensus guidelines 
(many of which recommend against treatment with these devices in general) is not necessary.  The decision is 
unfavorable as billing for daily IGRT which would not be furnished in accordance with accepted standards of 
medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IGRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Image Guidance Radiation Therapy (IGRT) (G6001).
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 medical records provided support the need for 
the requested IRF admission. The Plan denied your request. The Plan says based on the available information, 
admission to the RIF is not reasonable or necessary, as the enrollee's condition does not meet the Medicare 
rules.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for  chronic obstructive pulmonary disease (COPD), COVID-19, respiratory failure and was 
discharged home on December 6, 2023. There is ongoing weakness. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the medical record supports a need for physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code E0675 billed for dates of service January 11, 
2023, to February 9, 2023. 
 You asked the Plan to pay for the billed code. You say that the device was used to treat post-surgical 
lymphedema. The Plan denied your request. The Plan says there is insufficient evidence to justify 
reimbursement. 
 
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 code E0675 is not supported. Code E0675 is used in the treatment of peripheral arterial 
disease, not lymphedema. There is a more applicable code available for a device to treat lymphedema. 
Additionally, items that are used for a preventative service or function are excluded from coverage under 
Medicare. Based on this information, we decided that Medicare rules for coverage of the billed code have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure code E0675 billed for dates 
of service January 11, 2023, to February 9, 2023.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve nerve injection with guidance. 
 
You asked the Plan to pre-approve nerve injection. You say that you are appealing this denial. The Plan denied 
your request. The Plan says that this procedure is considered experimental/investigational. 
 
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. The Plan did not submit any medical records nor attempts to obtain records. We 
requested supporting medical records from the Plan, but none were submitted. Without supporting medical 
records, we cannot determine whether this procedure is medically reasonable and necessary for the enrollee. 
Therefore, the Plan has not shown that its decision to deny authorization for this service is correct. Therefore, 
we decided that the Plan has to pre-approve nerve injection with guidance.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the use of Eylea. 
 
You asked the Plan to pre-approve the medication. You say that Eylea is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says the enrollee does not meet the criteria for the use of 
Eylea. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 the medication. Our reviewer says that 
the enrollee does not meet the criteria. Our physician reviewer found Eylea is not Food and Drug 
Administration (FDA) approved for the treatment of retinal neovascularization following branch retinal vein 
occlusion unless there is macular edema present. This enrollee is not noted to have macular edema. Other 
standard treatments for retinal neovascularization includes scatter laser treatment.  
 
 
 
 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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the use of Eylea.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient diagnostic test provided on 
August 16, 2023. 
 
You asked the Plan to waive the copayment for an outpatient diagnostic test. You say that you disagree with 
the copayment. 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 $175 
copayment for outpatient diagnostic test/Medicare-coveredoutpatient diagnostic procedure. 
 
You have been asked to pay a $175 copayment for an outpatient diagnostic test. This item/service falls within 
the outpatient diagnostic test/Medicare-coveredoutpatient diagnostic procedure 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. However, since the allowed amount is 
less than the standard copayment, you only owe $169.25. Therefore, we decided that the Plan does not have to 
waive the copayment for an outpatient diagnostic test provided on August 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an immediate mandibular denture (D5140) provided on 
February 15, 2023 
 
You asked the Plan to pay for D5140. You say that you are not satisfied with your first denture. The Plan 
denied your request. The Plan says the requested dental service is not a covered benefit. 
 
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 an 
immediate mandibular denture (D5140) provided on February 15, 2023
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient services received May 17, 
2023, to May 22, 2023. 
 
You asked the Plan to waive the copayment for the inpatient services. You say that you feel you should not pay 
for coronary care. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $245 copayment per day for inpatient hospital care.  
 
The enrollee has been asked to pay a $245 copayment per day for a total of $1225 for the inpatient services. 
These services fall within the inpatient hospital care benefit category. This means that the enrollee has been 
asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayment for the inpatient services received May 17, 2023, to May 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 11, 2023. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on July 11, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate. 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that you are requesting reconsideration for 
the denied claim. The Plan denied your request. The Plan says the enrollee does not meet the requirements for 
approval. 
 
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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspirate remains experimental in spine surgery when used as bone graft 
material. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate.