Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99255 billed for date of service September 
24, 2022. 
 
You asked the Plan to pay for procedure code 99255. You say that you have provided medical records to 
support 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 99255 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99255 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code 99255 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99255 billed for date of service September 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you need these supplies. The Plan 
denied your request. The Plan says the requested supplies are not covered by Medicare or the Plan. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for labratory services provided on September 15, 2022. 
 
You asked the Plan to pay for labratory services. You say that this was medically necessary and should be 
covered. 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 labratory services 
provided on September 15, 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 
September 14, 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 $325 
copayment for outpatient surgery/Medicare-covered surgery or other services provided to you at an ambulatory 
surgical. 
 
You have been asked to pay a $325 copayment for an outpatient surgery. This item/service falls within the 
outpatient surgery/Medicare-covered surgery or other services provided to you at an ambulatory surgical 
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 September 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ankle and hip braces (11686, 12624), provided on 
October 13, 2022. 
 
You asked the Plan to pay for the ankle and hip braces. You say that the items should be covered. The Plan 
denied your request. The Plan says the submitted medical documentation does not mention the braces in the 
referring physician records received. 
 
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 relevant medical records which support medical necessity for the supplies provided 
in this case. There is no indication the braces were discussed or needed in the medical records. The record 
shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the ankle and hip braces (11686, 12624), provided on 
October 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
November 02, 2022. 
 
You asked the Plan to waive the copayment for a 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 $45 
copayment for physician/practitioner services/specialist. 
 
You have been asked to pay a $45 copayment for a specialist office visit. 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. Therefore, we decided that the Plan does not have to waive the copayment 
for a specialist office visit provided on November 02, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hip procedure provided on October 20, 2022. 
 
You asked the Plan to pay for a hip procedure. You say that this was medically necessary and should be 
covered. 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 hip procedure 
provided on October 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgeries provided on August 11, 
2022, to September 14, 2022. 
 
You asked the Plan to waive the copayment for outpatient surgeries. 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 $295 
copayment per visit for outpatient surgeries.  
 
You have been asked to pay a $295 copayment per visit for outpatient surgeries. The total amount you are 
being asked for the outpatient surgeries on 8/11/22 is $169.81 which is less than the required amount. The total 
amount you are being asked to pay is $1,054.81 ($295 + $295+ $295+ $129.81 = $1,054.81). This item/service 
falls within the outpatient surgeries 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 
outpatient surgeries provided on August 11, 2022, to September 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Spoken Rx. 
 
You asked the Plan to pre-approve Spoken Rx. You say that you are legally blind. You say that you need help 
with your medications. You also say that the requested device would allow you to continue to live alone. The 
Plan denied your request. The Plan says the requested item 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 does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve Spoken Rx.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant replacements (D6091), an implant supported 
lower denture (D6111), and semi-precision abutments placement (D6191). 
 
You asked the Plan to pre-approve implant services. You say that you would like the Plan to approve these 
services. The Plan denied your request. The Plan says the requested dental 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 pre-approve 
implant replacements (D6091), an implant supported lower denture (D6111), and semi-precision abutments 
placement (D6191).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that services requested are medically necessary. The 
Plan denied your request. The Plan says SNF services requested do not meet requirements required for 
approval. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical placement of implant body (D6010), the 
surgical access to an implant body (D6011), prefabricated abutment (D6056), and abutment support crown 
(D6058) for tooth #20, #29, and #31. 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denied dental 
services and have attached a letter from your physician. The Plan denied your request. The Plan says your 
benefit for the requested items or services 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 Plan's 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 items or services was exhausted with an authorization approved from 
January 18, 2023, to April 18, 2023. Therefore, we decided that the Plan does not have to pre-approve the 
surgical placement of implant body (D6010), the surgical access to an implant body (D6011), prefabricated 
abutment (D6056), and abutment support crown (D6058) for tooth #20, #29, and #31.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) 
joint. 
 
You asked the Plan to pre-approve RFA of the SI joint. You say that RFA of the SI joint is medically 
necessary. The Plan denied your request. The Plan says RFA of the SI joint is experimental/investigational. 
 
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 RFA of the SI joint. Our reviewer says 
that the requested RFA of the SI joint is not considered medically reasonable and necessary. Our physician 
reviewer found that according to the literature, sacral lateral nerve branch blocks and/or ablations/neurotomies 
for the diagnosis and/or treatment of sacroiliac joint mediated pain is considered experimental and 
investigational. Studies completed say that this procedure does not improve outcomes compared to standard 
treatment of SI joint pain. Radiofrequency ablation for denervation, whether performed using traditional, 
cooled, or pulsed radiofrequency is considered investigational and 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 RFA of the SI joint have not been met. Therefore, we decided that the Plan does 
not have to pre-approve RFA of the SI joint.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for injection administration and infusion 
therapy provided on September 16, 2022. 
 
You asked the Plan to waive the copayment for an injection and infusion. You say that you are solely being 
billed without the help of the Plan. 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 $345 
copayment for outpatient surgery provided in a hospital.  
 
You have been asked to pay a $247.96 copayment for an injection and infusion because the allowed amount for 
these services is less than the $345 copayment. This item/service falls within the outpatient surgery provided in 
a hospital 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 injection administration 
and infusion therapy provided on September 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bitewing x-ray. 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says your benefit for the requested 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 service was exhausted on date of service June 4, 2022. Specifically, the 
Plan contract states that bitewing x-rays are covered once every twelve months. You previously received this 
service on June 4, 2022, less than twelve months prior, which was paid for by the Plan. Therefore, you have 
exhausted the allowable benefit at this time. Therefore, we decided that the Plan does not have to pre-approve a 
bitewing x-ray.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the FreeStyle Libre continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that the requested CGM is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the requested CGM is not medically necessary. 
 
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 perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, 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 the CGM have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the FreeStyle Libre continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an endosteal implant (D6010), provided on November 10, 
2022. 
 
You asked the Plan to pay for dental implants. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says the rendered 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 
endosteal implant (D6010), provided on November 10, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a brain imaging, positron emission tomography (PET); 
metabolic evaluation (78608). 
 
You asked the Plan to pre-approve a PET scan of the brain. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the enrollee has a history of memory loss with progressive decline. A 
neuropsych evaluation was inconclusive. 
 
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 a PET scan of the brain. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found this service is only covered for 
individuals who meet diagnostic criteria for both AD and FTD. The records provided for review did not 
support that the enrollee met diagnostic criteria for both conditions (let alone one or the other). In as much, the 
enrollee would not meet the requirements for coverage of the requested service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a PET scan of the brain have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a brain imaging, positron emission tomography (PET); metabolic evaluation 
(78608).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the artery ultrasound (code 93925) 
provided on October 18, 2022. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that this ultrasound was ordered after a 
test provided during a home health visit. 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 $110 
copayment for Medicare-covered radiological diagnostic services.  
  
You have been asked to pay a $110 copayment for the ultrasound. This item/service falls within the outpatient 
diagnostic tests and therapeutic services benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for the artery ultrasound provided on October 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cataract surgery to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the cataract surgery. You say that you could not find positive reviews for 
the network providers and did not feel comfortable going to them. The Plan denied your request. The Plan says 
network providers are available to render necessary 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 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 
cataract surgery to be provided by an out-of-network (OON) provider.