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

 
We decided that the Plan does not have to waive the coinsurance for a Botox injection provided on October 1, 
2021. 
 
You asked the Plan to waive the coinsurance for a Botox injection. You say that you received approval for the 
Botox injections. You also say that previously approved injections were paid in full by your insurance 
company. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for in-network Part B drugs obtained in a providers office.  
 
You have been asked to pay $243.60, which is 20% of the allowed amount for a Botox injection ($1,218 
allowed amount x 20% coinsurance = $243.60). A Botox injection 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 coinsurance for a Botox injection provided on 
October 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Caresens test strips, control solution and Sterilance twist top 
lancets (A4253, A4256 and A4259) provided on December 30, 2020. 
 
You asked the Plan to pay for the Caresens test strips, control solution and Sterilance twist top lancets (A4253, 
A4256 and A4259).. You say that you would like reconsideration because the billed supplies are medically 
necessary. The Plan denied your request. The Plan says this is not the preferred brand of diabetic supplies. 
 
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 pay for the Caresens test strips, control solution and 
Sterilance twist top lancets (A4253, A4256 and A4259).. Our reviewer says that the requested items/services 
are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no 
reason given why the member must use the prescribed brand instead of  the preferred brand. 
 
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 Caresens test strips, control solution and Sterilance twist top lancets 
(A4253, A4256 and A4259). have not been met. Therefore, we decided that the Plan does not have to pay for 
Caresens test strips, control solution and Sterilance twist top lancets (A4253, A4256 and A4259) provided on 
December 30, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office consultation (99243) provided October 9, 2021. 
 
You asked the Plan to pay for the consultation. You say that the enrollee has expressed an interest in continuing 
to work with you due to the working relationship that has been established. The Plan denied your request. The 
Plan says this provider type is not eligible in the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the office consultation (99243) provided 
October 9, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have reimburse you for the gasoline (A9270) provided on October 6, 2021. 
 
You asked the Plan reimburse you for the transportation service. You say that you were informed by the plan to 
get your reimbursement, you had to keep your receipt. You say that you were never told that it had to be 
transportation company like Lyft or Uber. You also say that The Plan denied your request. The Plan says 
transportation from a third party is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. 
The Plan follows the same rule.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Medicare rules for coverage of the transportation service have not been met. Specifically, routine 
transportation services, including gasoline charges, are not covered by the Plan. Therefore, we decided that the 
Plan does not have reimburse you for the gasoline (A9270) provided on October 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and 
management of an established patient (99336) rendered by the out-of-network (OON) provider on October 25, 
2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the domiciliary or rest home visit for the evaluation and management of an established 
patient (99336) rendered by the out-of-network (OON) provider on October 25, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infrared therapy (97026), manual therapy techniques 
(97140), therapeutic exercises (97110, 97530), neuromuscular reeducation (97112), and the electrical 
stimulation (G0283) rendered by the out-of-network (OON) provider on July 14, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the infrared therapy (97026), manual therapy techniques (97140), therapeutic 
exercises (97110, 97530), neuromuscular reeducation (97112), and the electrical stimulation (G0283) rendered 
by the out-of-network (OON) provider on July 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel (0242U) 
provided on July 28, 2021. 
 
  You asked the Plan to pay for the targeted genomic sequence analysis panel (0242U). You say that this service 
is considered separate from the hospital encounter and place of service 81 is accurate. You say that the 
laboratory must bill directly for the service and the service should be paid. The Plan denied your request. The 
Plan says the place of service must reflect the location of the patient when the specimen was obtained. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules say that the Place of Service 
(POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service. 
 
We find that CPT code 0242U is not supported in the medical record. Specifically, this claim was billed with 
the laboratory place of service code, but the records do not support the members face-to-face service was 
rendered in a laboratory. Based on this information, we decided that Medicare rules for coverage of the targeted 
genomic sequence analysis panel (0242U) have not been met. Therefore, we decided that the Plan does not 
have to pay for the targeted genomic sequence analysis panel (0242U) provided on July 28, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services (G0300), and skilled physical 
therapy services (G0151) provided on October 5, 2021 to October 7, 2021 by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for the home health services. You say that authorization was obtained for the 
services. The Plan denied your request. The Plan says authorization was not obtained prior to the dates of 
service in this case. The Plan also says that the services were not urgent or emergent in nature. 
 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 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 the skilled nursing services (G0300), and skilled 
physical therapy services (G0151) provided on October 5, 2021 to October 7, 2021 by an out-of-network 
(OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve shoe inserts. 
 
You asked the Plan to pre-approve foot orthotics. You say that the item is medically necessary. The Plan 
denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve shoe 
inserts.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic comprehensive preventive medicine 
reevaluation and management (99397), the office visit (99213), and the annual wellness visit (G0439) rendered 
by the out-of-network (OON) provider on October 26, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the periodic comprehensive preventive medicine reevaluation and management 
(99397), the office visit (99213), and the annual wellness visit (G0439) rendered by the out-of-network (OON) 
provider on October 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient psychiatric hospital services provided from  
May 26, 2021, through May 31, 2021. You asked the Plan to pay for the inpatient psychiatric hospital services. The Plan denied your request. The 
Plan says CMS presumes that a state or local government that has a Medicare beneficiary in custody under a 
penal statue has financial obligations to pay for the cost of healthcare items and services. The plan will require 
evidence that the conditions have been met before paying for any healthcare services 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare presumes that a State or local 
government that has custody of a Medicare beneficiary under a penal statute has a financial obligation to pay 
for the cost of healthcare items and services unless the State can demonstrate that it meets these conditions. 
 
We looked at the file and Medicare rules. The file shows that the enrollee was admitted to the hospital in the 
custody of a local government agency under a penal statute, and the record does not show that either of the 
special coverage conditions were met by the local government, so Medicare does not cover this stay. Therefore, 
we decided that the Plan does not have to pay for inpatient psychiatric hospital services provided from 
May 26, 2021, through May 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial upper denture (D5213), and partial lower 
denture (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that do you not have any teeth. You say that the 
partial dentures you have are broken. You say you were not aware of the plan changes. You say that you have 
not received a new card or new information. You also say that The Plan denied your request. The Plan says 
partial dentures are not listed as covered services. 
 
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 partial dentures are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
partial upper denture (D5213), and partial lower denture (D5214).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be improving and should require only short-term additional 
acute care services that can safely be administered at the current facility until appropriate for a lower level of 
care. There are no services at the LTACH that the enrollee requires that are not already available and covered at 
the current facility. Transfer to a lower level of care may be considered when treatment has completed. 
 
 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cholecystectomy (47600) provided on June 7, 2021. 
 
You asked the Plan to pay for the cholecystectomy. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says an edit exists between CPT codes 47120 and 
47600. 
 
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 47600 
 is a column II code to column I code 47120. This code pair does not allow for a modifier to bypass the edit. 
Therefore, we decided that the Plan does not have to pay for the cholecystectomy (47600) provided on June 7, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99205), the preventive medicine counseling 
and/or risk factor reduction intervention (99401), and the documentation review of current medications by an 
eligible clinician (G0487) rendered by the out-of-network (OON) provider on August 25, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the office visit (99205), the preventive medicine counseling and/or risk factor 
reduction intervention (99401), and the documentation review of current medications by an eligible clinician 
(G0487) rendered by the out-of-network (OON) provider on August 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nuclear medicine imaging of the thyroid (78014). 
 
You asked the Plan to pre-approve nuclear medicine imaging of the thyroid. You say that this is medically 
reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria 
for coverage have 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 nuclear medicine imaging of the 
thyroid. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the record indicates that the enrollee has a nontoxic, 
benign single thyroid nodule by biopsy in the setting of normal thyroid function tests and multi-nodular 
disease. The literature does not support the performance of a thyroid scan in this setting. The record provided 
does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested 
service. The elements of the coverage criteria are not satisfied. The requested service is not recommended 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of nuclear medicine imaging of the thyroid have not been met. Therefore, we 
decided that the Plan does not have to pre-approve nuclear medicine imaging of the thyroid (78014).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upholstered chair. 
 
You asked the Plan to pre-approve the chair. You say that this is medically necessary. The Plan denied your 
request. The Plan says furniture is not covered. 
 
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 an upholstered chair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be improving and should require only short-term additional 
acute care services that can safely be administered at the current facility until the enrollee is stable enough for 
transfer. There are no services at the LTACH that the enrollee requires that are not already available and 
covered at the current facility. Transfer to a lower level of care may be considered when treatment has 
completed. 
 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.