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

 
We decided that the Plan does not have to pre-approve the Special Supplemental Benefits for the Chronically 
Ill (SSBCI). 
 
You asked the Plan to pre-approve the SSBCI benefits. You say that you are appealing this denial. The Plan 
denied your request. The Plan says there is no documentation that you meet all three criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the SSBCI benefits have not been met. Specifically, we have confirmed that you do not have one 
of the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have 
to pre-approve the Special Supplemental Benefits for the Chronically Ill (SSBCI).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hearing aids (V5100) to be rendered by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the dental items. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says dental items/services from an out-of-network 
provider are not covered by your supplemental 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. 
 
You are requesting dental items from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items are not covered under this benefit when received from an out-
of-network provider. Therefore, we decided that the Plan does not have to pre-approve hearing aids (V5100) to 
be rendered by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99360 provided on October 4, 2022. 
 
You asked the Plan to pay for procedure code 99360. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says standby services are not payable to physicians. 
 
The Plan must follow Medicare rules. Medicare rules say that standby services are not payable to physicians. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of procedure code 99360 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99360 provided on October 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SSBCI benefits. 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you believe the enrollee is eligible for the 
SSBCI benefits. The Plan denied your request. The Plan says the enrollee does not meet the criteria to be 
eligible for SSBCI benefits. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
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 meet the 
intensive care management criteria listed in the EOC, which is 2 or more inpatient admission in the last 60 
days, or 3 or more emergency room visits in the last 60 days. Therefore, we decided that the Plan does not have 
to pre-approve SSBCI benefits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cleaning (D1110) and resin-based composites (D2330, 
D2391, and D2393) for tooth #27, #28, and #31 provided by an out-of-network provider on December 13, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you were told the provider was in-network and 
the dental services should be covered. The Plan denied your request. The Plan says the dental services were 
received from an out-of-network provider and are not covered by your supplemental 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. 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a cleaning (D1110) and resin-based composites (D2330, D2391, and D2393) for tooth #27, #28, and 
#31 provided by an out-of-network provider on December 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary visit, skin lesion trimming, and nail 
debridement. provided on November 23, 2022. 
 
You asked the Plan to pay for a domiciliary visit, skin lesion trimming, and nail debridement.. You say that the 
nursing facility is responsible to obtain authorization. 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 domiciliary visit, skin 
lesion trimming, and nail debridement. provided on November 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam, the ophthalmic diagnostic imaging, the 
intravitreal injection, and the Part B drug injection provided on August 15, 2022, by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for the eye exam, the ophthalmic diagnostic imaging, the intravitreal injection, and 
the Part B drug injection. You say that none of the services require prior authorization. The Plan denied your 
request. The Plan says the provider was out-of-network and there was no referral for the services. 
 
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 
eye exam, the ophthalmic diagnostic imaging, the intravitreal injection, and the Part B drug injection. We 
found no exception that would require the Plan to pay for the eye exam, the ophthalmic diagnostic imaging, the 
intravitreal injection, and the Part B drug injection. Therefore, we decided that the Plan does not have to pay 
for the eye exam, the ophthalmic diagnostic imaging, the intravitreal injection, and the Part B drug injection 
provided on August 15, 2022, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance transportation provided on 
October 8, 2022. 
 
You asked the Plan to waive the copayment for an ambulance transportation. You say that you could not walk 
and needed the ambulance. 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 $265 
copayment per day for ambulance services.  
 
You have been asked to pay a $265 copayment for an ambulance transportation. This item/service falls within 
the ambulance 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 an 
ambulance transportation provided on October 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar facet joint radiofrequency ablation (RFA) 
procedure. 
 
You asked the Plan to pre-approve a lumbar facet joint RFA procedure. You say that the services are necessary. 
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan follows Medicare rules. Medicare rules say that an initial thermal RFA of cervical, thoracic, or 
lumbar paravertebral facet joint (medial branch) nerves is considered medically reasonable and necessary for 
patients who have had at least two (2) medically reasonable and necessary diagnostic MBBs, with each one 
providing a consistent minimum of 80% sustained relief of primary (index) pain (with the duration of relief 
being consistent with the agent used). 
 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 lumbar facet joint RFA procedure. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found a second 
confirmatory block must be performed and the patient has to have at least 80% pain relief from this diagnostic 
block. Since a second set has not been performed, the request is deemed not medically reasonable and 
necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a lumbar facet joint RFA procedure have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a lumbar facet joint radiofrequency ablation (RFA) procedure.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the MRI. You say that you are requesting the MRI scan to be approved. The 
Plan denied your request. The Plan says the requested provider is an OON provider and the services have 
already been approved with an in-network provider as well as previous MRI scans have been completed with 
them. 
 
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 magnetic resonance imaging (MRI) 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 a continuous glucose monitor (CGM) and related 
supplies 
 
You asked the Plan to pre-approve the CGM and related supplies. You say that it would be beneficial for the 
enrollee to have a CGM. The Plan denied your request. The Plan says the Medicare criteria was not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
  We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the CGM and related supplies have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor (CGM) and related supplies
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dry pressure mattress (E0184) and hospital bed, with 
weight capacity greater than 350 pounds, but less than or equal to 600 pounds (E0303). 
 
You asked the Plan to pre-approve a dry pressure mattress and hospital bed. The Plan denied your request. The 
Plan says the enrollee's height and weight measurements do not qualify for bariatric equipment. 
 
The Plan must follow Medicare rules. Medicare rules say that a heavy duty extra wide hospital bed (E0301, 
E0303) is covered if the beneficiary meets one of the criteria for a fixed height hospital bed and the 
beneficiary's weight is more than 350 pounds, but does not exceed 600 pounds. Medicare rules also say that 
mattresses are covered only where a hospital bed is medically necessary. 
 
 
  We looked at the file and Medicare rules. Specifically, the record shows that the enrollee only weighs 188 
pounds, and does not meet the weight requirement for the requested hospital bed. Since the hospital bed is 
denied, the requested mattress is also denied. Based on this information, we decided that Medicare rules for 
coverage of a dry pressure mattress and hospital bed have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a dry pressure mattress (E0184) and hospital bed, with weight capacity greater 
than 350 pounds, but less than or equal to 600 pounds (E0303).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown-porcelain fused to predominantly base metal 
(D2751) for tooth #6. 
 
You asked the Plan to pre-approve a crown. You say that you are requesting reconsideration for the denial of a 
crown. The Plan denied your request. The Plan says the x-rays show a crown is not needed to fix your tooth. 
 
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. The Plan covers a crown when 
the services are medically necessary and reasonable.  
 
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 crown. Our reviewer says that the 
service is not medically necessary. 
 
 
 Our physician reviewer found the provided x-rays for tooth #6 indicate a distal carious lesion and an existing 
restoration that appears to involve the DI corner of the tooth. After endodontic treatment, there will still be a 
significant amount of remaining tooth structure, such that a crown would not be indicated. An anterior tooth 
having had root canal therapy is insufficient in itself to require a crown restoration. As there is sufficient tooth 
remaining for a conventional restoration, a crown is not necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a crown have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a crown-porcelain fused to predominantly base metal (D2751) for tooth #6.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) 
(E0730) provided on October 21, 2022. 
 
You asked the Plan to pay for the TENS. You say that E0730 is an accepted procedure code. The Plan denied 
your request. The Plan says TENS units for the treatment of chronic lower back pain is not covered by 
Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that TENS is not reasonable and necessary for the 
treatment of CLBP.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the TENS have not been met. Therefore, we decided that the Plan does not have to pay for the 
transcutaneous electrical nerve stimulation (TENS) (E0730) provided on October 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the vision item or service (V2799) 
provided on August 1, 2022. 
 
You asked the Plan to provide additional payment for the routine eye wear. You say that this provider was less 
expensive. The Plan denied your request. The Plan says this claim processed correctly.  
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services up to $50 per year when provided out-of-network. 
 
We looked at the file and the Plan's rules. The routine eye wear was purchased out-of-network. The Plan 
provided documentation that the full $50 benefit was applied to this claim.  Therefore, we decided that the Plan 
does not have to provide additional payment for the vision item or service (V2799) provided on August 1, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you would like another set of orthotics so you 
can play handball. 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 you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for a flu shot provided on October 27, 2022, by an 
out-of-network provider. 
 
You asked the Plan to reimburse you for the flu shot. You say that you went to this pharmacy because it was 
quicker than getting the flu shot from the clinic you went to in 2020. The Plan denied your request. The Plan 
says you are contractually required to obtain this service from network providers. 
 
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 reimburse you 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 
services at issue. We found no exception that would require the Plan to reimburse you for these services. 
Therefore, we decided that the Plan does not have to reimburse you for a flu shot provided on  
October 27, 2022, by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342, 88360, and 88381 billed for 
date of service April 5, 2022. 
 
You asked the Plan to pay for procedure code(s) 88341, 88342, 88360, and 88381. You say that you would like 
the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says these codes are 
included in the facility payment and are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88342, 88360, 
and 88381. This means there is both a professional and technical component for the CPT code(s). In this case, 
an appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88341, 
88342, 88360, and 88381. Based on this information, we decided that Medicare rules for coverage of procedure 
codes 88341, 88342, 88360, and 88381 have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure code(s) 88341, 88342, 88360, and 88381 billed for date of service April 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 57282 and 52000 billed for date of service 
November 8, 2022. 
 
You asked the Plan to pay for procedure codes 57282 and 52000. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says payment for codes 57282 and 
52000 are bundled into payment for code 58260. 
 
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 codes 
57282 and 52000 are column II codes to column I code 58260. This claim has not been billed with an 
appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 57282 and 52000 billed for 
date of service November 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the diagnostic colonoscopy provided on 
March 11, 2021. 
 
You asked the Plan to waive the coinsurance for the colonoscopy. You say that you have only had to pay $50 
in the past for the same procedure. 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 20% 
coinsurance for each Medicare-covered surgery.  
 
You have been asked to pay up to 20% coinsurance of the allowed amount for the colonoscopy. You have been 
asked to pay $1,376.55. This item/service falls within the outpatient surgery benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the coinsurance for the diagnostic colonoscopy provided on March 11, 2021.