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

 
We decided that the Plan does not have to waive the copayment for an outpatient diagnostic tests provided on 
February 10, 2023. 
 
You asked the Plan to waive the copayment for an outpatient diagnostic tests. 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 $60 
copayment for outpatient diagnostic tests/ultrasound. 
 
You have been asked to pay a $60 copayment for an outpatient diagnostic tests. This item/service falls within 
the outpatient diagnostic tests/ultrasound 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 outpatient diagnostic tests provided on February 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 5, 2022, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that the provider was not aware they were not in-
network. The Plan denied your request. The Plan says this was not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on December 5, 2022, by 
an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endodontic therapy on tooth #31 (D3330), an 
intraorifice barrier on tooth #2, 30, and 31 (E3911), and therapeutic parenteral drugs on tooth # 2, 30, and 31 
(D9610). 
 
You asked the Plan to pre-approve the dental services. You say that you are requesting reconsideration of the 
denied authorization. The Plan denied your request. The Plan says that intraorifice barriers and therapeutic 
parenteral drugs are not covered by your dental benefits. The Plan also says that your benefit for endodontic 
therapy has 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, intraorifice barriers and therapeutic 
parenteral drugs are not among those covered under this benefit. The records show your benefit for endodontic 
therapy was exhausted on the initial authorization request. Therefore, we decided that the Plan does not have to 
pre-approve endodontic therapy on tooth #31 (D3330), an intraorifice barrier on tooth #2, 30, and 31 (E3911), 
and therapeutic parenteral drugs on tooth # 2, 30, and 31 (D9610).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular artery embolization.  
 
You asked the Plan to pre-approve genicular artery embolization. You say that genicular artery embolization is 
medically necessary. The Plan denied your request. The Plan says while this relatively new technique is 
showing promise as an alternative to a total knee arthroplasty, at present, there is a lack of randomized 
controlled studies with longer term follow-up that consistently demonstrate the short and long-term success of 
this procedure. The procedure has not been shown to be sufficiently demonstrated to be safe and effective. As 
such, it is considered to be unproven and therefore 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 genicular artery embolization. Our 
reviewer says that the requested genicular artery embolization is not considered medically reasonable and necessary in this case. Our physician reviewer found that this enrollee was being treated for bilateral primary 
osteoarthritis of the knee; stiffness of the right knee; stiffness in the left knee; unilateral primary osteoarthritis 
of the right knee; and osteoarthritis of the left knee. The enrollee presented with bilateral knee pain rated at 
1-2/10 on the VAS. The exam reveals bilateral valgus angulation. There is bilateral knee crepitus noted. There 
is pain with palpation on the lateral joint lines as well as the lateral patella bilaterally. Bilateral pre-patella 
bursa swelling is noted. The range of motion was increased from previous bilaterally. Varus/valgus stress 
testing are positive bilaterally. However, there is limited published, large-scale, long-term peer-reviewed 
literature that shows this request to be an effective and/or safe treatment for the noted pathology. While the 
studies are noted to be promising, further studies/research is needed to corroborate that geniculate artery 
embolization is as good as or better than standard treatments for knee osteoarthritis. No compelling rationale is 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception. 
Therefore, the requested genicular artery embolization 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 genicular artery embolization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve genicular artery embolization.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve True Metrix Glucose test strips. 
 
You asked the Plan to pre-approve the True Metrix Glucose test strips. You say that the medical records 
support the need for the True Metrix Glucose test strips The Plan denied your request. The Plan says that non-
preferred diabetic test strips and meters are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has no preferred brand of diabetic supplies listed and 
havent given any other reason to support the denial. The Evidence of Coverage (EOC), page 53 states for all 
people who have diabetes (insulin and non-insulin users). Covered services include: supplies to monitor your 
blood glucose: blood glucose monitor, blood glucose test strips, lancet devices and lancets, and glucose-control 
solutions for checking the accuracy of test strips and monitors. The EOC does not list preferred products. 
Therefore, we decided that the Plan has to pre-approve True Metrix Glucose test strips.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office/outpatient visit (procedure code 99212) rendered on 
November 29, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 99212-25 (1 Units) remains not supported. 
 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, the CPT Code Manual definition of code 99212 is "Office or other outpatient visit for the 
evaluation and management of an established patient, which requires a medically appropriate history and/or 
examination and straightforward medical decision making. When using time for code selection, 10-19 minutes 
of total time is spent on the date of the encounter." 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the medical records provided do 
not include sufficient documentation to validate that CPT 99212 was performed as a significant, separately 
identifiable evaluation and management service. Therefore, 99212 is included in the global period of CPT 
20610 and it is not appropriate to report 99212 with a 25 modifier. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for an office/outpatient visit (procedure code 99212) rendered on November 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on October 31, 2022. 
 
You asked the Plan to pay for the office visit. You say that this provider had been approved on previous claims. 
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 office visit provided 
on October 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 27, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that the enrollee was referred for this service. The Plan 
denied your request. The Plan says this was not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on March 27, 2023, 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 Freestyle Libre 2 continuous glucose monitor (CGM) 
Sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre 2 CGM Sensor. You say that you have diabetes, and you 
cannot finger poke yourself due to carpal tunnel in both hands. The Plan denied your request. The Plan says 
you do not meet criteria for approval of the requested CGM sensor. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin or have a 
history of problematic hypoglycemia Based on this information, we decided that Medicare rules for coverage 
of a Freestyle Libre 2 CGM Sensor have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) Sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 08, 2022. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary and should be covered. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on September 08, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility care provided on November 17, 2022. 
 
You asked the Plan to pay for skilled nursing facility care. You say that you believe the services are medically 
necessary. 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 skilled nursing facility 
care provided on November 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit for evaluation provided on February 20, 2023. 
 
You asked the Plan to pay for home visit for evaluation. You say that the assisted living facility is responsible 
to obtain prior authorization for all patients. 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 home visit for 
evaluation provided on February 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound provided on February 15, 2023. 
 
You asked the Plan to pay for the ultrasound. 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 the ultrasound provided 
on February 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the debridement of nails provided on 
January 21, 2023. 
 
You asked the Plan to waive the copayment for the debridement of nails. You say that you do not think that 
there is a 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 $50 
copayment for in and out-of-network Medicare-covered podiatry services provided in an office or home setting. 
 
You have been asked to pay a $50 copayment for the debridement of nails. This item/service falls within the in 
and out-of-network Medicare-covered podiatry services provided in an office or home setting 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. However, since the 
allowed amount is less than the standard copayment, you only owe $38. Therefore, we decided that the Plan 
does not have to waive the copayment for the debridement of nails provided on January 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on October 08, 2022, to 
October 18, 2022. 
 
You asked the Plan to pay for a nursing facility visit. You say that you depend on the facility staff to verify 
eligibility and 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 nursing facility visit 
provided on October 08, 2022, to October 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on February 21, 2023. 
 
You asked the Plan to pay for the office visit. You say that you have been going to this provider for over 40 
years. 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 office visit provided 
on February 21, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for outpatient surgery on March 09, 2023.  
 
You asked the Plan to waive the deductible for outpatient surgery. You say that you want to appeal the amount 
being charged. 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. Your 
contract with the Plan says that there is a $1,250 deductible which applies to outpatient surgery, including 
services provided at hospital outpatient facilities and ambulatory surgical center.  
 
The item or service you asked the Plan to waive the deductible for falls within the outpatient surgery, including 
services provided at hospital outpatient facilities and ambulatory surgical center benefit category. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is a $1,250 deductible which applies to 
outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical center. 
This cost sharing is a contractual obligation that had not been met at the time outpatient surgery was received 
on March 9, 2023. Therefore, we decided that the Plan does not have to waive the deductible for outpatient 
surgery on March 09, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for EKG provided on June 23, 2022. 
 
You asked the Plan to waive the copayment for EKG. You say that you believe the services are medically 
necessary. 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 $35 
copayment for hospice care. 
 
You have been asked to pay a $35 copayment for EKG. This item/service falls within the hospice 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. Therefore, we 
decided that the Plan does not have to waive the copayment for EKG provided on June 23, 2022.