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

 
We decided that the Plan does not have to pay for ER visit, and self-administered drugs provided on July 17, 
2023, to July 19, 2023. 
 
You asked the Plan to pay for ER visit and the medication. You say that this was medically necessary and 
should be covered. The Plan denied your request. The Plan says the medication is not covered as a medical 
benefit under the Plan and there is a $65 copayment for ER services.  
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing 
information (such as copayments, deductibles and coinsurance).  
 
You have been asked to pay a $65 copayment for the ER visit. This item/service falls within the emergency 
care benefit category. You have also been asked to pay the full cost of the self-administered drugs since they 
are not covered by Medicare Part B. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. Therefore, we decided that the Plan does not have to pay for the ER visit, and self-
administered drugs provided from July 17, 2023, to July 19, 2023.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Chiropractic manipulative treatment provided on August 
22, 2023. 
 
You asked the Plan to pay for the Chiropractic manipulative treatment. You say that you are appealing the 
claim payment denial. 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 Chiropractic 
manipulative treatment provided on August 22, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on July 21, 2023. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you cannot afford 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 $100 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $100 copayment for an ultrasound. This item/service falls within the 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 an ultrasound provided on July 21, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on 
April 27, 2023, to May 19, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 
copayment for in-network inpatient hospital care. 
 
You have been asked to pay a $295 copayment for the inpatient hospital stay. This item/service falls within the 
in-network inpatient hospital care 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. You have been asked to pay a total of $1,475 for the inpatient hospital stay 
($295 copayment x 5 days = $1,475). You have not been charged for the day you were discharged. Therefore, 
we decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on April 
27, 2023, to May 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided May 18, 
2023, to June 6, 2023. 
 
You asked the Plan to pay for a pneumatic compression device. You say that you are requesting 
reconsideration based on medical necessity for this enrollee and evidence based medical literature that 
substantiate the efficacy of the treatment rendered. The Plan denied your request. The Plan says this service is 
not a covered benefit. Claims for E0675 will be denied as not reasonable and necessary.  
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) provided May 18, 2023, to June 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture visits provided from February 5, 2023, to 
April 21, 2023. 
 
You asked the Plan to pay for the acupuncture visits. You say that these visits were needed to relieve shoulder 
pain. The Plan denied your request. The Plan says acupuncture treatments for shoulder pain are not covered 
under any circumstance by the plan. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services furnished outside of the 
United States are only covered under limited, specified circumstances. The Plan has a worldwide coverage 
benefit that goes beyond Medicares coverage. For that reason, the Plans rules apply to this case. The Plan 
covers worldwide emergency and urgent care services. Urgently needed services are defined as those needed 
because of an unforeseen illness or condition and it is not reasonable to get the services from the Plan. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, acupuncture for shoulder pain is not a covered benefit 
under any circumstance. Therefore, we decided that the Plan does not have to pay for the acupuncture visits 
provided from February 5, 2023, to April 21, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided from June 24, 2022, to 
November 18, 2022. 
 
You asked the Plan to pay for psychotherapy. You say that your mental health provider is not qualified enough 
to provide adequate mental health services. The Plan denied your request. The Plan says this provider is not 
part of 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 psychotherapy provided from  
June 24, 2022, to November 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve topical fluoride varnish (D1206), core buildup (D2950) 
and porcelain or ceramic crown (D2740). 
 
You asked the Plan to pre-approve the dental services. You say that this is an emergency as you are in pain. 
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 core buildup was exhausted on date of service August 23, 2019. The record also shows 
that the benefit for a porcelain or ceramic crown was exhausted on September 11, 2019. Topical fluoride 
varnish (D1206) is not a covered benefit. Therefore, we decided that the Plan does not have to pre-approve 
topical fluoride varnish (D1206), core buildup (D2950) and porcelain or ceramic crown (D2740).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (88368, 88369, 88377, 88184, 88189, 88237, 
88264, 88291, 88313, 88305, 85097, 88311) provided on July 25, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.   
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for lab services (88368, 88369, 88377, 88184, 88189, 88237, 88264, 88291, 88313, 
88305, 85097, 88311) provided on July 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot inserts (L3000). 
 You asked the Plan to pre-approve foot orthotics. You say that the inserts are medically necessary for the 
enrollee because they have arthritis of the foot and diabetes. 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 requested foot inserts (L3000) are not a covered inserts for a person with diabetes, and 
the enrollee 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 foot inserts (L3000).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the electrical stimulation, the self-care/home 
management training, the radiologic examinations, the office visit, and the chiropractic manipulative treatments 
provided from June 14, 2023, to June 28, 2023. 
 
You asked the Plan to pay more for the electrical stimulation, the self-care/home management training, the 
radiologic examinations, the office visit, and the chiropractic manipulative treatments. You say that you were 
told you had a 40% coinsurance, and no exclusions were listed or explained. The Plan denied your request. The 
Plan says the services are not covered benefits and the chiropractic services processed correctly. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. 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 40% for Medicare-covered chiropractic services at an out-
of-network specialist's office. 
 
The records show that the electrical stimulation, the self-care/home management training, the radiologic 
examinations, the office visit are not manual manipulation of the spine. However, you have been asked to pay 
40% of the allowed amount for each of the chiropractic manipulative treatments. The allowed amount was 
$28.39 for each of the treatments. ($28.39 x 40% = $11.36). Therefore, we decided that the Plan does not have 
to pay more for the electrical stimulation, the self-care/home management training, the radiologic 
examinations, the office visit, and the chiropractic manipulative treatments provided from June 14, 2023, to 
June 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 19, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration of the denied 
claim. 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 May 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for crown recementation (D2920) provided on June 13, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental 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 pay for crown 
recementation (D2920) provided on June 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genicular nerve block. 
 
You asked the Plan to pre-approve the genicular nerve block. The Plan denied your request. The Plan says the 
genicular nerve block is not medically necessary. 
 
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 genicular nerve block. Our reviewer 
says that the genicular nerve block is not medically necessary. Our physician reviewer found that the enrollee 
has a history of bilateral knee pain due to osteoarthritis. However, genicular nerve blocks and genicular nerve 
ablations are considered investigational and not medically necessary for the treatment of chronic knee pain. 
Therefore, the requested genicular nerve block for the left knee is not medically reasonable or 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 genicular nerve block have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the genicular nerve block.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for implant maintenance procedures (D6080 x4) provided on 
May 1, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental 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 pay for implant 
maintenance procedures (D6080 x4) provided on May 1, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tiering exception for the OneTouch Verio test strip 
 
You asked the Plan to pre-approve the tier exception. You say that you are asking for a lower copayment. The 
Plan denied your request. The Plan says tiering exceptions are not available for medical supplies. 
 
The Plan must follow Medicare rules. Medicare rules state that tiering exceptions cannot apply to Part B drugs. 
Tiering exceptions are only applicable to Part D drugs.  
 
We looked at the file and Medicare rules. The drug(s) you are requesting is considered a Part B drug. As a 
result, no tiering exceptions can be made. Therefore, we decided that the Plan does not have to pre-approve a 
tiering exception for the OneTouch Verio test strip
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting LTACH services for 
the enrollee. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for 
admission to an LTACH. 
 
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 is receiving appropriate care in the current setting and the documentation 
does not support that LTACH services are medically appropriate 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 00840 provided on August 7, 2023. 
 
You asked the Plan to pay for procedure code 00840. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on August 6, 2023. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for procedure code 
00840 provided on August 7, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99283 billed for date of service August 5, 
2023. 
 
You asked the Plan to pay for procedure code 99283. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 99283 is bundled into 
payment for code 99284. 
 
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 99283 
is a column II code to column I code 99284. 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 code 99283 billed for date of service August 5, 2023.