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

 
We decided that the Plan does not have to waive the copayment for emergency room visit provide on January 
11, 2022. 
 
You asked the Plan to waive the copayment for emergency care. You say that you received a letter of denial for 
a procedure and did not want to pay for 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 $110 
copayment for emergency care.  
 
You have been asked to pay $110 copayment for emergency care. This item/service falls within the emergency 
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 emergency room visit provide on 
January 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a VIA Disc procedure. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee suffers from midline pack 
pain. The Plan denied your request. The Plan says the efficacy of the treatment is unproven. 
 
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 requested services. Our physician 
reviewer found that the requested procedure is experimental. More research is needed to show its safety and 
efficacy. Therefore, the request is not medically necessary. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a VIA Disc procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that this is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the criteria for the CGM have not been met. 
 
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 appear to have 
diabetes mellitus and does not appear to use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic CGM have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the remaining balance for the limited oral evaluation (D0140), 
bitewings x-rays (D0272) and intraoral imaging (D0220) provided on April 5, 2022, and the resin-based 
composites (D2391) provided on May 2, 2022. 
 
You asked the Plan to pay the remaining balance for the dental services. You say that the provider damaged 
your teeth, and they should pay your bill for these services. The Plan denied your request. The Plan says the 
allowed amount for each dental service was paid and you are responsible for the remaining amount. 
 
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, dental services are usually only covered when received 
from a network provider. The Plan decided to pay the allowed amount for each service, but you are responsible 
for any remaining balance. Therefore, we decided that the Plan does not have to pay the remaining balance for 
the limited oral evaluation (D0140), bitewings x-rays (D0272) and intraoral imaging (D0220) provided on 
April 5, 2022, and the resin-based composites (D2391) provided on May 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service February 26, 
2022, to March 25, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that due to complications from staff shortages 
due to the pandemic and the damages created by Hurricane Ida in this geographic area, the normal systems of 
operations were not followed by the providers staff. You also say there was some confusion regarding when 
the enrollee would be moving from this area. The Plan denied your request. The Plan says the billed code is 
invalid for Medicare purposes. 
 
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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service February 26, 2022, to March 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve regenerative peripheral nerve interface (RPNI) surgery 
for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is experimental, investigational, and unproven. 
 
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 in this case, the record indicates that the enrollee has a history of breast cancer and requires 
operative intervention. There is insufficient literature to support the safety and efficacy of the requested 
procedures for the enrollee's clinical condition. The record provided does not establish the medical necessity 
and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage 
criteria are not satisfied. 
 
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 regenerative peripheral nerve interface (RPNI) surgery for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transperineal placement of biodegradable material, 
peri-prostatic, single or multiple injection(s), including image guidance, when performed (55874). 
 
You asked the Plan to pre-approve injections. You say that you have submitted additional clinicals to support 
your request for the transperineal placement of biodegradable material peri prostatic injections. The Plan 
denied your request. The Plan says the requested services are not reasonable and necessary, and the health plan 
has no contractual obligation to cover services that are not covered by Medicare. 
 
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 injections. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found transperineal spacer placement (Polyethylene glycol (PEG) Hydrogel) is considered medically 
reasonable and necessary when an enrollee has clinically localized (only found in one area of the body) prostate 
cancer, and the prostate cancer is determined to be low or favorable intermediate risk. Based on the clinical 
information provided the enrollee has unfavorable intermediate risk cancer. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of injections have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a transperineal placement of biodegradable material, peri-prostatic, single or multiple 
injection(s), including image guidance, when performed (55874).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ground mileage (A0425) provided on October 3, 2021. 
 
You asked the Plan to pay for the ambulance service. You say that this service is covered by Medicare and 
should be paid as such. The Plan denied your request. The Plan says the enrollees claim would be covered 
under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until 
the last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to 
verify the enrollees coverage before rendering services and to know proper billing procedures for a Medicare 
Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.   
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the ground mileage (A0425) provided on October 3, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for administration of an injection and 
ceftriaxone sodium (a Medicare Part B prescription drug) provided on May 17, 2022. 
 
You asked the Plan to waive the cost-sharing for drug administration and Part B drug. You say that this should 
be covered at 100% as part of the X-Ray you 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 $750 
deductible for drug administration and 20% coinsurance for Part B drug. At the time this claim was processed, $320.35 of the $750 deductible had been met. The allowed amount of the drug administration if $13.99, 
resulting in a deductible amount of $13.99. The allowed amount of the Part B drug is $2.04, resulting in a 
coinsurance amount of $0.41. Therefore, your total cost-sharing responsibility is $14.40 ($13.99 deductible 
amount + $0.41 coinsurance amount = $14.40). 
 
You have been asked to pay $750 deductible for drug administration and 20% coinsurance for Part B drug. 
These items/services fall within the "physician/practitioner services, including doctor's office visits" and 
"Medicare Part B prescription drugs" benefit categories. 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-sharing 
for administration of an injection and ceftriaxone sodium (a Medicare Part B prescription drug) provided on 
May 17, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on July 9, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for imaging services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for imaging services provided on July 9, 2021, 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 pneumatic compressor (E0651) and a segmental 
pneumatic appliance for use with pneumatic compressor (E0667). 
 
You asked the Plan to pre-approve intermittent limb compression device. You say that the pneumatic 
compression device is medically necessary, and the enrollee meets the criteria. The Plan denied your request. 
The Plan says the enrollee does not meet coverage criteria. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
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 intermittent limb compression device. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found there is no 
documentation that the pneumatic compression device at issue in this case meets all Medicare criteria for 
medically reasonable and necessary for the enrollee. Provided records do not document trial and failure of four 
weeks of conservative therapy with re-assessments that include detailed measurements, obtained in the same 
manner and with reference to the same anatomic landmarks, prior to and at the conclusion of the various trials 
and therapy, with bilateral comparisons where appropriate. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of intermittent limb compression device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a pneumatic compressor (E0651) and a segmental pneumatic 
appliance for use with pneumatic compressor (E0667).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the trigger point injection (20553) and preventive medicine 
counseling and/or risk factor reduction intervention (99401) provided on January 14, 2022. 
 
You asked the Plan to pay for the practitioner services. You say that the services have been covered previously. 
You say that you do not understand why they are denying now. The Plan denied your request. The Plan says 
the services denied correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the trigger point injection (20553) and preventive medicine counseling and/or risk factor reduction intervention (99401) provided on January 14, 
2022. have been met. Specifically, there were no records provided to support the medical necessity of the 
services in this case. Additionally, the preventive medicine counseling is a non-covered service. Therefore, we 
decided that the Plan does not have to pay for the trigger point injection (20553) and preventive medicine 
counseling and/or risk factor reduction intervention (99401) provided on January 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for a resin-based composite filling on tooth 
#17 (D2391) and resin-based composite fillings on tooth #8, 9, 11, and 18 (D2330) provided on May 23, 2022. 
 
You asked the Plan to reduce the coinsurance for fillings. You say that you were told the provider was in-
network. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
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 70% 
coinsurance for out-of-network fillings.  The record shows you received fillings by an out-of-network provider. You have been asked to pay 70% 
coinsurance of the allowed amount for each filling. 
 
Code Allowed Amount Coinsurance 
D2391 $180 $126 
D2330 $165 $115.50 
D2330 $165 $115.50 
D2330 $165 $115.50 
D2330 $165 $115.50 
Total  $588 
 
Fillings fall within the dental 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 reduce the coinsurance for 
a resin-based composite filling on tooth #17 (D2391) and resin-based composite fillings on tooth #8, 9, 11, and 
18 (D2330) provided on May 23, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve care in an out-of-network skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve out-of-network SNF care. You say that the Plan facility is too far away, and 
you have concerns about the care you will receive there. The Plan denied your request. The Plan says there are 
contracted providers who are able to provide the necessary care, and it is not necessary to go to an out-of-
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. In addition, Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is 
considered accessible to an enrollee if contract providers are available within reasonable distance and travel 
time from the enrollees home. 
 
The requested provider in this case is not a network provider with the Plan. We were able to confirm that the 
Plan has contract providers located within reasonable distance and travel time from your home who can 
provide out-of-network SNF care. Specifically, there is a facility less than ten miles from your home which is 
contracted with the Plan. Under Medicare rules, this means that contract providers are accessible to you. 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 care in an out-of-network skilled nursing facility (SNF).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve positron emission tomography (PET) scan services. 
 
You asked the Plan to pre-approve the PET scan. You say that you have had cancer for 2 years and the doctor 
has recommended this PET scan since September. You say that the requested scan is medically necessary. The 
Plan denied your request. The Plan says that the enrollee is asymptomatic and on surveillance. The Plan says 
that the coverage for criteria have therefore not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 the PET scan. Our reviewer says that 
the criteria for coverage have been met. Our physician reviewer found the enrollee has a medical history of 
Kidney Cancer after a right nephrectomy diagnosed 2 years ago. The enrollee is not undergoing active 
treatment and he is under surveillance by a doctor currently every 6 months. The enrollee had computed 
tomography (CT) of Chest in September due to shortness of breath. On previous CT imaging from August of 
2021, the enrollee had lung nodules and was follow-up for nodules. Findings showed several "essentially 
stable" non-calcified pulmonary nodules. Also noted that it reflects a "benign process" and does not require 
additional follow-up. At latest visit the enrollee reported fatigue, daytime somnolence and snoring. The doctor 
is requesting PET/CT scan for restaging. Three PET/CT scans are covered to guide subsequent management of 
anti-tumor treatment strategy after completion of initial anti-cancer therapy. The requested PET scan is related 
to subsequent treatment strategy and is medically necessary. 
 
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 PET scan have been met. Therefore, we decided that the Plan has to pre-
approve positron emission tomography (PET) scan services.  
 
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.