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

 
We decided that the Plan does not have to pay for dental services provided on January 16, 2023. 
 
You asked the Plan to pay for the dental services. You say that the Plan should reconsider this denial. The Plan 
denied your request. The Plan says the Plan has paid the full $600 benefit for dental services in 2023. 
 
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 the Plan paid $600.53 toward this claim, which exhausts the $600 yearly benefit maximum for dental 
coverage. Therefore, we decided that the Plan does not have to pay for dental services provided on January 16, 
2023.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 93458 billed for date of service November 11, 2022. 
 
You asked the Plan to pay for the billed services. You say that the documentation supports the charges. The 
Plan denied your request. The Plan says that a covered diagnosis has not been billed. 
 
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. 
 
We looked at the file and the rules. The Plan denied services as the diagnosis codes billed are not listed under 
codes that support medical necessity. However, the rules state the diagnosis code does not assure coverage of a 
service. The Local Coverage Article does not include codes that do not support medical necessity. No other 
rationale for denial was submitted. The Plan has not made reasonable and diligent efforts to gather and forward 
to us information regarding their decision to deny your request.  Therefore, we decided that the Plan has to pay 
for procedure code 93458 billed for date of service November 11, 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 periodontal maintenance procedure (D4910) provided on 
December 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. 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 January 5, 2022 (D4910) 
July 12, 2022 (D1110). Therefore, we decided that the Plan does not have to pay for periodontal maintenance 
procedure (D4910) provided on December 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient rehabilitation services and a 
specialist office visit provided on August 16, 2022, to September 12, 2022. 
 
You asked the Plan to waive the copayment for outpatient rehabilitation services and 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 $20 
copayment per visit for outpatient rehabilitation services and a $40 copayment for physician/practitioner 
services/specialist.  You have been asked to pay a $20 copayment per visit for outpatient rehabilitation services and a $40 
copayment for a specialist office visit. The total amount you are being asked to pay for rehab services is $60 
($20 x 3 visits = $60). The total amount you are being asked to pay $100 ($60 + 40 = $100). This item/service 
falls within the outpatient rehabilitation services and 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 outpatient rehabilitation services and a specialist office visit 
provided on August 16, 2022, to September 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 16, 2022. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services provided. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on August 16, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health provided on August 19, 2022. 
 
You asked the Plan to pay for outpatient mental health. You say that you are requesting reconsideration. 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 outpatient mental health 
provided on August 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on May 17, 2022, to September 20, 
2022. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. 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 office visit provided on 
May 17, 2022, to September 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on November 28, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the enrollees doctor is responsible for 
obtaining authorization for these services. 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 the laboratory services 
provided on November 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-rays provided on October 08, 2022. 
 
You asked the Plan to pay for x-rays. You say that you are requesting reconsideration. 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 x-rays provided on 
October 08, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve single axis, fluid swing and stance phase control 
(L5828) stance flexion feature, adjustable (L5845) fluid stance extension, dampening feature, with or without 
adjustability (L5848) above knee or hip disarticulation, knee extension assist (L5850) microprocessor control 
feature, swing and stance phase, includes electronic sensor(s), any type (L5856). 
 
You asked the Plan to pre-approve the microprocessor knee. You say that providing the enrollee with a 
mechanical knee or lesser functioning knee will contribute to multiple falls which can result in injury prosthetic 
rejection, and the inability to progress in prosthetic rehabilitation. The Plan denied your request. The Plan says 
the requested microprocessor knee exceeds the enrollee's needs. 
 
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 microprocessor knee. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found per LCD L33787 as there is no objective criteria including physical therapy notes 
indicating the enrollee will be able to walk at a K3 level and require the more advanced microprocessor knee. 
The enrollee was walking in the community before the second amputation, but now has two amputations and 
the second is above knee. The record does not provide specific information why the microprocessor 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 microprocessor knee have not been met. Therefore, we decided that the Plan 
does not have to pre-approve single axis, fluid swing and stance phase control (L5828) stance flexion feature, 
adjustable (L5845) fluid stance extension, dampening feature, with or without adjustability (L5848) above knee 
or hip disarticulation, knee extension assist (L5850) microprocessor control feature, swing and stance phase, 
includes electronic sensor(s), any type (L5856).
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 January 9, 
2023. 
 
You asked the Plan to pay for procedure code 99100. You say that the services are covered under the surgeons 
and facilities authorizations. 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 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
99100 billed for date of service January 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a suction device to be used with a PureWick catheter 
system. 
 
You asked the Plan to pre-approve a suction device. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that suction devices are not covered because they are 
not primarily medical in nature.  
 
While a suction device may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. The suction device is considered investigational. Therefore, we decided that the Plan does not have to 
pre-approve a suction device to be used with a PureWick catheter system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic (D6245) for tooth #8 and #9. 
 
You asked the Plan to pre-approve the dental services. You say that you have not used the full benefit based on 
the authorization you received. 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 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 item or service was exhausted on February 17, 2023 when the Plan 
authorized one pontic for tooth #10 and three retainer crowns for tooth #6, #7 and #11. Therefore, we decided 
that the Plan does not have to pre-approve a pontic (D6245) for tooth #8 and #9.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate (20939) for a spinal surgery. 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that the requested services are a medical 
necessity for you. 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 bone marrow aspirate. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no specific indication provided to support the request for bone marrow aspirate for the approved surgery. There is a lack of large volume, long-term, peer-reviewed outcome studies to 
support the use of bone marrow aspirate for your medical condition. There is no compelling rationale presented 
or extenuating circumstances noted to support the medical necessity of this request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate (20939) for a spinal surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transplant evaluation to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a transplant evaluation to be provided by an OON provider. You say that the 
services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able 
to provide these services. Therefore, coverage criteria have not been met. 
 
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 
a transplant evaluation to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and two or more power seating system motors (E2311), a harness (E2313), an expandable controller (E2377) 
and other accessories, bracket, footplate width extension (K0108). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that the enrollee needs the requested 
wheelchair and accessories due to her group 3 diagnosis of left side hemiplegia, ischemic stroke, 
cerebrovascular accident, high fall risk, high risk of pressure ulcers, osteoarthritis, and weakness in BUE and 
BLE which has limited ability to perform independent pressure relief. The Plan denied your request. The Plan 
says although there are three requested power options (tilt, recline and elevating leg rests), there is not a 
medical need to control these power options through the joystick. The enrollee does not meet criteria for the 
requested accessories. 
 
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 wheelchair accessories. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has a left hemiplegia and 3+/5 strength in the right upper extremity. The 
enrollee has adequate strength to manage standard power drive switches on her wheelchair. There is not a 
medical need to control these power options through the joystick. The request for footplate accessories cannot 
be approved, as this is incorrectly coded and unbundled. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wheelchair accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection between wheelchair controller and two or more power 
seating system motors (E2311), a harness (E2313), an expandable controller (E2377) and other accessories, 
bracket, footplate width extension (K0108).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for medical supplies and an outpatient 
diagnostic test provided on November 29, 2022, to December 12, 2022. 
 
You asked the Plan to waive the cost share for medical supplies and an outpatient diagnostic test. You say that 
you disagree with the cost share. 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 outpatient diagnostic test/medical supplies and a $125 copayment for outpatient diagnostic test/ 
Medicare-covered radiological diagnostic services.  
 You have been asked to pay a 20% coinsurance for medical supplies and a $125 copayment for an outpatient 
diagnostic test. The total allowed amount for the medical supplies is $440.34. You are being asked to pay 
$88.06 ($44.034 x 20% = $88.06). The total amount you are being asked to pay for all services is $213.06 
($88.06 + $125 = $213.06). This item/service falls within the outpatient diagnostic test/medical 
supplies/Medicare-covered radiological diagnostic 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 cost share for medical supplies and an outpatient diagnostic test provided on November 29, 2022, 
to December 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you have diabetes and schizophrenia, and 
have not received your card. You also say that you need the card for food. The Plan denied your request. The 
Plan says the criteria for eligibility have not been met. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).