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

 
We decided that the Plan does not have to pay for procedure code S2900 billed for date of service May 17, 
2022. 
 
You asked the Plan to pay for procedure code S2900. You say that you would like the Plan to reconsider their 
denial of payment. 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 S2900 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code S2900 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S2900 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S2900 billed for date of service May 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on 
September 7, 2022. 
 
You asked the Plan to waive the copayment for specialist office visit. 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 $20 
copayment for physician/practitioner services/specialist's office.  
 
You have been asked to pay a $20 copayment for specialist office visit. This item/service falls within the 
physician/practitioner services/specialist's office 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 specialist office visit provided on September 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code E0570 provided on August 5, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for procedure code E0570 provided by an OON provider. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network 
care. 
 
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 procedure code E0570 provided on August 5, 
2022, 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 desktop video magnifier. 
 
You asked the Plan to pre-approve a desktop video magnifier. You say that you are legally blind and and this 
item would allow you to become more stable and independent member of society. The Plan denied your 
request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order for the requested item. Therefore, we decided that the Plan 
does not have to pre-approve a desktop video magnifier.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on August 14, 2022. 
 
The enrollee asked the Plan to pay for the ambulance response and treatment with no transport. The enrollee 
said that they believe this was medically necessary, and they would like to appeal this service. The Plan denied 
the enrollees request. The Plan says the Medicare ambulance benefit is a transportation benefit and with no 
transport there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on August 14, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on August 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an adult prophylaxis (D1110). 
 
You asked the Plan to pre-approve the dental services. You say that your dentist feels that you should go four 
times a year so your gums will not get any worse. 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 June 9, 2022. Therefore, 
we decided that the Plan does not have to pre-approve an adult prophylaxis (D1110).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 provided on August 9, 2022. 
 
You asked the Plan to pay for procedure code 99232. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the enrollee enrolled in hospice from July 23, 
2022, through August 3, 2022. The Plan says, per Medicare guidelines, the provider needs to submit the claim 
to Original Medicare for the services provided on August 9, 2022. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated.  
The enrollee ended Medicare Hospice benefits on August 3, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for procedure code 
99232 provided on August 9, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a brain imaging, positron emission tomography (PET) 
scan; metabolic evaluation (78608). 
 
You asked the Plan to pre-approve this service. You say that the requested service is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of the 
requested service. 
 
The Plan must follow Medicare rules. Medicare rules say that a Fluorodeoxyglucose (FDG) Positron Emission 
Tomography (PET) scan is considered reasonable and necessary in patients with a recent diagnosis of dementia 
and documented cognitive decline of at least 6 months, who meet diagnostic criteria for both Alzheimers 
Disease (AD) and Frontotemporal Dementia (FTD). 
 
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 this service. Our reviewer says that the 
requested service is not medically necessary.  Our physician reviewer found that in this case the enrollee is noted to have a form of progressive dementia. The 
records however do not make mention of the enrollee having either Alzheimers Disease or Frontotemporal 
Dementia. Additionally, the records do not indicate that the enrollee has met the diagnostic criteria for both 
conditions. In this case, the enrollee does not meet the baseline requirements for coverage of a PET scan in 
dementia as defined by Medicare rules. Therefore this service cannot be adjudged to be reasonable and 
necessary at this time.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a brain imaging, positron emission tomography (PET) scan; metabolic evaluation (78608).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic exercises (97110). 
 
You asked the Plan to pre-approve these services. You say that the requested services are medically necessary 
for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of 
the requested services.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
  
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 these services. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that based on the medical records provided, there is no documentation 
that indicates the requested therapy is generally accepted as specific and effective therapy for the enrollees 
condition. Based on the available records, the enrollee appears to have no objective deficits in strength, range 
of motion, or ability to perform her activities of daily living. The provided records document that the enrollees 
strength, range of motion, and ability to perform activities of daily living have been within normal limits during 
the time of her treatments. After at least nine therapy treatments provided already, records do not support that 
the complexity of the enrollees conditions are such that the skills of a professional therapist are required to 
achieve further improvement in the enrollees symptoms or functional status. Further utilization of a home 
treatment program appears appropriate at this point. Repetitive exercise does not require the expertise of a 
professional skilled physical therapist.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve therapeutic exercises (97110).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve repair of nasal valve collapse with low energy, temperature-
controlled subcutaneous/submucosal remodeling. 
 
You asked the Plan to pre-approve repair of nasal valve collapse with low energy, temperature-controlled 
subcutaneous/submucosal remodeling. You say that the services are necessary. The Plan denied your request. 
The Plan says that medical necessity has not been established. Therefore, coverage criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 repair of nasal valve collapse with low 
energy, temperature-controlled subcutaneous/submucosal remodeling. Our reviewer says that the requested 
items/services are considered medically reasonable and necessary in this case. Our physician reviewer found 
low energy, temperature-controlled (ie, radiofrequency) subcutaneous/submucosal remodeling has been shown 
in the medical literature to be a durable and well-tolerated non-invasive treatment option for patients suffering 
from congestion due to nasal obstruction. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of repair of nasal valve collapse with low energy, temperature-controlled 
subcutaneous/submucosal remodeling have been met. Therefore, we decided that the Plan has to pre-approve 
repair of nasal valve collapse with low energy, temperature-controlled subcutaneous/submucosal remodeling.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan, of the soft tissues of the neck; 
with contrast material(s) (70491). 
 
You asked the Plan to pre-approve this service. You say that the requested service is medically necessary for 
the enrollee. The Plan denied your request. The Plan says that the requested service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve this service. Our reviewer says that the 
requested service is medically necessary. Our physician reviewer found that the enrollee has a history of an 
intermittent sore throat. He had a laryngoscopy on November 29, 2022, which revealed recurrent acute 
tonsillitis, sinusitis, and reflux disease. Computed tomography of the neck has been recommended to look at 
the upper esophagus and the soft tissues of the pharynx. This is a reasonable approach after a laryngoscopy was 
provided. The requested exam should be approved as the enrollee has reflux disease and a persistent sore 
throat. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have been met. Therefore, we decided that the Plan has to pre-
approve a computed tomography (CT) scan, of the soft tissues of the neck; with contrast material(s) (70491).  
 
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 anti-reflective coating (V2750) provided on August 17, 
2022. 
 
  You asked the Plan to pay for anti-reflective coating (V2750). You say that you did not ask for this coating. 
You also say that the doctor should not have recommended this if it is not covered by insurance. The Plan 
denied your request. The Plan says because reflective coating is not a covered benefit, your request for payment 
of this service is denied. 
 
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 when you receive one pair of standard lenses and frames every two 
years. 
 
We looked at the file and the Plan's rules. The Plan rules say that they cover one pair of standard lenses and 
frames every two years. Anti-reflective coating is excluded from this benefit. Based on this information, we 
decided that the Plan's rules for coverage of anti-reflective coating (V2750) have not been met. Therefore, we 
decided that the Plan does not have to pay for anti-reflective coating (V2750) provided on August 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body (D6010), semi-
precision abutment placement (D6191), implant/abutment supported removable denture for edentulous arch-
mandibular (D6111), and replacement of replaceable part of semi-precision or precision attachment of 
implant/abutment supported prosthesis, per attachment (D6091). 
 
You asked the Plan to pre-approve the dental services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says these services are not covered under your benefit plan. 
 
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 pre-approve 
surgical placement of implant body (D6010), semi-precision abutment placement (D6191), implant/abutment 
supported removable denture for edentulous arch-mandibular (D6111), and replacement of replaceable part of 
semi-precision or precision attachment of implant/abutment supported prosthesis, per attachment (D6091).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service September 
26, 2022. 
 You asked the Plan to pay for procedure code 76705. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 76705 is bundled into 
payment for code 93976. 
 
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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service September 26, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic CGM system. 
 
You asked the Plan to pre-approve a CGM system. You say that the requested CGM system is medically 
necessary. The Plan denied your request. The Plan says that the coverage criteria has 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 use insulin 
with at least three daily injections and does not require frequent self-adjustment of insulin dosage based on the 
blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a 
CGM system have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
therapeutic CGM system.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Medicare Part B prescription drugs 
provided on October 12, 2022. 
 
You asked the Plan to waive the copayment for Medicare Part B prescription drugs. 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a 20% coinsurance for Medicare Part B prescription drugs. The total allowed 
amount for the drugs is $2,223. You are being asked to pay $444.60 ($2,223 x 20% = $444.60). This 
item/service falls within the Medicare Part B prescription drugs 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 Medicare Part B prescription drugs provided on October 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on June 3, 
2022. 
 
You asked the Plan to waive the copayment for an outpatient surgery. 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 $200 
copayment for outpatient surgery.  
 
You have been asked to pay a $200 copayment for an outpatient surgery. This item/service falls within the 
outpatient surgery 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 outpatient surgery 
provided on June 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a rest home visit provided on June 09, 2022. 
 
You asked the Plan to pay for a rest home visit. You say that there is a medical necessity pre-established with 
the enrollee and the facility for them to provide services to the enrollees needing care 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 rest home visit 
provided on June 09, 2022.