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

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service August 30, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you have provided medical records for this 
date of service. The Plan denied your request. The Plan says procedure code 99100 is considered bundled and 
not separately payable. 
 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service August 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 33 fractions of radiotherapy (77014, G6012). 
 
You asked the Plan to pre-approve 33 fractions of radiotherapy. You say that the additional fractions are 
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 33 fractions of radiotherapy. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the unacceptable treatment plan that was submitted in the case file justifies the 
need for intensity modulated radiotherapy (IMRT) and not for adding additional fractions of radiation, which is 
not standard of care. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 33 fractions of radiotherapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 33 fractions of radiotherapy (77014, G6012).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on November 26, 2022. 
 You asked the Plan to pay for laboratory services. You say that these services were necessary and are supported 
as billed. The Plan denied your request. The Plan says there are insufficient records to support the necessity of 
these services. 
 
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 laboratory services have been met. 
Specifically, the limited records provided do not include a signed physician order and progress notes from the 
referring provider to support the intention for these tests to be performed and show that they were medically 
necessary. Therefore, we decided that the Plan does not have to pay for laboratory services provided on 
November 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat with toilet top (E1399). 
 
You asked the Plan to pre-approve a raised toilet seat. You say that the enrollee does have toilet, but it is 
moldy. The enrollee has osteoarthritis and a knee replacement with difficulty walking. The Plan denied your 
request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While a raised toilet seat may be appropriate for F. Rosa, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat with toilet top 
(E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of a CardioMEMS device (33289, C2624). 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
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 a CardioMEMS device. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there remains a dearth of randomized, blinded clinical studies examining long-
term clinical outcomes establishing the value of CardioMEMS in patient management. 
 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 CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve implantation of a CardioMEMS device (33289, C2624).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the 
Plan' 48-trip limit. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you need additional trips to 
dialysis appointments. The Plan denied your request. The Plan says the requested trips exceed your benefit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the Plan' 
48-trip limit.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for a take-home supply of methadone (code G2078) provided on 
December 19, 2022. 
 
You asked the Plan to pay for a take-home supply of methadone. You say that you have been enrolled in the 
Medicare program to provide Opioid Treatment Program (OTP) services since January 1, 2020. The Plan 
denied your request. The Plan says that the claim for these drugs was billed by the physician, not the opioid 
treatment program (OTP) facility. The rules say that only an entity enrolled with Medicare as an OTP can bill 
these codes. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the OTP is the billing provider and is Substance Abuse and Mental 
Health Services Administration (SAMHSA) certified. The rules cited by the Plan do not provide a valid reason 
to deny this claim given that the OTP meets the Medicare coverage criteria. This provider continues to use the 
professional claim, which is allowed under Medicare rules. Therefore, we decided that the Plan has to pay for a 
take-home supply of methadone (code G2078) provided on December 19, 2022.  
 
 
 If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve Glucocard Vital blood glucose test strips. 
 
You asked the Plan to pre-approve the blood glucose test strips. You say that you are appealing the denied 
item. The Plan denied your request. The Plan says that that the requested item is not a preferred brand. 
 
The Plan must follow Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers 
as preferred as long the MA plan discloses DME coverage limitation with the EOC and ANOC. 
 
We looked at your contract with the Plan. We did not see any evidence that the Plan disclosed the DME 
coverage limitation of preferred brands in their EOC. The Plan contract does not clearly say there is a list of 
preferred brands or state that enrollees must use a preferred brand. This means that the Plan did not follow 
Medicare rules for disclosure of using preferred brands for the blood glucose test strips. Therefore, we decided 
that the Plan has to pre-approve Glucocard Vital blood glucose test strips.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on May 4, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that this patient was transported multiple times 
on the date of service and the ambulance run reports for each trip are submitted. The Plan denied your request. 
The Plan says a physicians office is not a covered destination for non-emergency situations.  
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctors office is not a covered destination.  
 
The services you have asked the Plan to pay for are ambulance transport services to a doctors office. 
Therefore, we decided that the Plan does not have to pay for ambulance services provided on May 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft (D7953) provided on November 3, 
2022. 
 
You asked the Plan to pay for a bone replacement graft. You say that this dental work was medically necessary. 
The Plan denied your request. The Plan says dental services are not covered. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for a bone replacement graft 
(D7953) provided on November 3, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the echocardiography provided on January 
03, 2023. 
 
You asked the Plan to waive the copayment for the echocardiography. You say that you already paid 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 $5 
copayment for in-network outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $5 copayment for the echocardiography. This item/service falls within the in-
network 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. Therefore, we decided that the Plan 
does not have to waive the copayment for the echocardiography provided on January 03, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental implants and associated services. 
 
You asked the Plan to pre-approve dental implants and associated services. You say that your tooth is infected. 
The Plan denied your request. The Plan says these 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 
dental implants and associated services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial mandibular denture (D5214). 
 
You asked the Plan to pre-approve a partial mandibular denture. You say that you would like the Plan to 
approve this 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 pre-approve a 
partial mandibular denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic casts (D0470) provided on December 21, 2022. 
 
You asked the Plan to pay for the diagnostic casts (D0470). You say that you felt you did your due diligence in 
following procedures and should be reimbursed for what the insurance allows. The Plan denied your request. 
The Plan says this service is not covered under the benefit package. 
 
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 diagnostic 
casts (D0470) provided on December 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for endodontic therapy, molar tooth (D3330) provided on 
July 20, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you have a $1,000 yearly benefit for 
dental services and only $297.50 was paid. You also say that you would like the remaining yearly benefit 
balance for 2022 to be applied to this date of service. The Plan denied your request. The Plan says you are 
responsible for any charged amount above the Plans cost-sharing amount when your services are received 
from an out-of-network provider. 
 
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. 
 
 You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for endodontic therapy, molar tooth (D3330) 
provided on July 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on August 5, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for chiropractic services. You say that this should be covered. The Plan denied your 
request. The Plan says this was not authorized. 
 
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 chiropractic services 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 pay for the pneumatic compression device provided on November 3, 
2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on November 3, 2022.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for the speech therapy services provided on June 28, 2022. 
 
You asked the Plan to pay for the speech therapy services. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says that the place or type of service billed is not valid. 
 
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. Review of the file shows that the Plan has denied this claim due to the place or 
type of service billed is not valid. However, the documentation does not include explanation on why this place 
of service cannot be billed with the services rendered. No Medicare rules were provided to support this denial. 
No other Plan denial rationale was provided. Therefore, the Plan did not substantiate their denial. Therefore, we 
decided that the Plan has to pay for the speech therapy services provided on June 28, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a partial flexible upper denture (D5225) provided on August 
2, 2022. 
 
You asked the Plan to pay for the dental service. You say that you paid for the denture, and you were under the 
impression that the Plan would pay most of the bill. The Plan denied your request. The Plan says the denial of 
payment for this service is correct, because the partial flexible upper denture is not covered by the 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a partial 
flexible upper denture (D5225) provided on August 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 06, 2022. 
 
You asked the Plan to pay for an office visit. 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 an office visit provided 
on October 06, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on August 31, 
2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on August 31, 2022.