Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a portable x-ray provided on December 27, 2022. 
 
You asked the Plan to pay for a portable x-ray. 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 portable x-ray 
provided on December 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the battery-operated ice auger purchased on December 27, 
2022. 
 
You asked the Plan to pay for the battery-operated ice auger. You say that in 2021 you purchased ice fishing 
equipment and was reimbursed for this purchase through the Plan's supplemental benefit. You also say that 
your plan for 2022 was to use your supplemental benefit to purchase a battery-operated ice auger to complete 
the equipment needed for this activity. The Plan denied your request. The Plan says an ice auger is a non-
covered service, and does not fit within any of the defined categories of the supplemental benefit program.  
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. However, the Plan offers a supplemental benefit that exceeds Medicare coverage. For that 
reason, the Plans coverage rules apply in this case.   
 
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. Though the Plan 
offers a supplemental benefit in excess of Medicare coverage, a battery-operated ice auger is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the battery-operated ice 
auger purchased on December 27, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency department services (procedure code 99285) 
rendered on February 7, 2023. 
 
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 the code was denied correctly, and the denial was upheld. 
 
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 99285 is "Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function."
 
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 in this case, the documentation 
does not support the CPT code 99285. The documentation available for review does not support that the 
presenting problems were of high severity or that the medical decision was of high complexity. 
 
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 emergency department services (procedure code 99285) rendered on February 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the endoscopy procedure provided on 
November 01, 2022. 
 
You asked the Plan to reduce the copayment for the endoscopy procedure. You say that you should only be 
charged a $175 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 $250 
copayment for in-network outpatient surgery, including services provided at hospital outpatient facility. 
 
You have been asked to pay a $250 copayment for the endoscopy procedure. This item/service falls within the in-network outpatient surgery, including services provided at hospital outpatient facility 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 reduce the copayment for the endoscopy procedure provided on November 01, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for an extraction, erupted tooth (D7210), deep sedation/general anesthesia 
 first 15 minutes (D9222), and each subsequent 15 minute increment (D9223) provided on January 6, 2023. 
 
You asked the Plan to pay for the dental services represented by codes D7210, D9222 and D9223. You say that 
you disagree with the decision and you also say  that the date of service was incorrect. The Plan denied your 
request. The Plan says that you have exhausted your dental benefit. 
 
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 enrollee provided documentation showing that the services in 
dispute were the extraction, erupted tooth (D7210), deep sedation/general anesthesia  first 15 minutes 
(D9222), each subsequent 15 minute increment (D9223) that were provided on January 6, 2023. The Plan has 
not provided a 2023 EOC and has not demonstrated that any supplemental dental benefits have been exhausted 
Therefore, we decided that the Plan has to pay for an extraction, erupted tooth (D7210), deep sedation/general 
anesthesia  first 15 minutes (D9222), and each subsequent 15 minute increment (D9223) provided on January 
6, 2023.  
 
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 a new patient office visit, and related services provided on 
August 11, 2022. 
 
You asked the Plan to pay for a new patient office visit, and related services. You say that this is supported in 
the records. 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 new patient office 
visit, and related services provided on August 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ultrasound provided on January 11, 2023. 
 
You asked the Plan to pay for an ultrasound. 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 ultrasound provided 
on January 11, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the emergency room service provided on 
November 08, 2022, to November 13, 2022. 
 
You asked the Plan to reduce the copayment for the emergency room service. You say that this service should 
qualify for an inpatient admission. 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 emergency care. 
 
You have been asked to pay a $50 copayment for the emergency room service. This item/service falls within 
the emergency 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 reduce the copayment for the emergency room 
service provided on November 08, 2022, to November 13, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit provided on June 
19, 2022, to June 20, 2022. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that you were admitted as 
an inpatient and should not have to pay this 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 $90 
copayment for emergnecy care. 
 
You have been asked to pay a $90 copayment for the emergency room visit. This item/service falls within the 
emergnecy 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. The record shows this claim was approved and you are responsible for the cost share amount. Therefore, 
we decided that the Plan does not have to waive the copayment for the emergency room visit provided on June 
19, 2022, to June 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve the injection. The Plan denied your request. The Plan says  an epidural 
steroid injection 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 injection. Our reviewer says that the 
enrollee does not meet the coverage criteria. Our physician reviewer found that the enrollee has chronic low 
back pain and has had conservative therapy and an epidural steroid injection on May 19, 2023, which gave 
them 50% pain relief for 2 weeks. However, the coverage criteria have not been met as the LCD requires 50% 
pain relief for 3 months. Therefore, the request is not medically reasonable and 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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an epidural steroid injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 standard power wheelchair (K0823). 
 
  You asked the Plan to pre-approve a group 2 standard power wheelchair. You say that you have no one to push 
you in a manual wheelchair. You also say that you would like to go to the store without having someone to 
push you due to living alone. The Plan denied your request. The Plan says there is no face-to-face encounter 
with a prescriber to evaluate you and assess medical necessity for the item. The Plan also says there is no 
clinical assessment of your functional mobility deficits, nor assessment of why these cannot be accommodated 
by an alternative optimally configured wheelchair base. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. The rules also say that for equipment to be covered, it must be appropriate and needed for use inside 
the home. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a group 2 standard power wheelchair 
have been met. Medical records were not provided for this case. The record shows that the Plan attempted to 
obtain this information, but it was not received. Without medical records we are unable to determine if you 
meet the criteria for coverage. The documentation also shows that item at issue in this appeal is for use outside 
of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use 
outside the home. Therefore, we decided that the Plan does not have to pre-approve a group 2 standard power 
wheelchair (K0823).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on January 3, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on January 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing, and related services provided on November 16, 
2022. 
 
You asked the Plan to pay for drug testing, and related services. You say that this is supported in the records. 
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 drug testing, and related 
services provided on November 16, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six days of Transcranial Magnetic Stimulation (TMS) 
services (90869, 90868). 
 
You asked the Plan to pre-approve six days of TMS services. 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 retreatment may be considered for patients who met 
the guidelines for initial treatment and subsequently developed relapse of depressive symptoms if the patient 
responded to prior treatments as evidenced by a greater than 50% improvement in standard rating scale 
measurements for depressive symptoms. (e.g., GDS, PHQ-9, BDI, HAM-D, MADRS, QIDS or IDS-SR 
scores). 
 
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 six days of TMS services. Our reviewer says that the services are not medically necessary. Our physician reviewer found based on the information 
provided, you do not meet the clinical criteria as you have no documentation of a rating scale or the 
improvement documented above a previous Transcranial Magnetic Stimulation. The use of transcranial 
magnetic stimulation is considered experimental and investigational for Obsessive-Compulsive Disorder. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of six days of TMS services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve six days of Transcranial Magnetic Stimulation (TMS) services (90869, 
90868).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve branch injection. 
 
You asked the Plan to pre-approve the injection. You say that the enrollee has completed steroid injections, gel 
injections and previously underwent a total knee arthroplasty. The Plan denied your request. The Plan says a 
genicular nerve branch injection 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 injection. Our reviewer says that a 
genicular nerve branch injection is not medically necessary. Our physician reviewer found that the use of 
genicular nerve blocks and radiofrequency ablations in post operative total knee replacement patients is the 
subject of ongoing clinical trials. The enrollee is not enrolled in a clinical trial, and the request is considered 
experimental 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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a genicular nerve branch injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PalinGen skin substitute. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee has not failed standard wound care.  
 
The Plan follows Medicare rules. Medicare rules say that skin substitute grafts are only covered under certain 
medical indications. 
 
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 requested services. Our physician 
reviewer found that the enrollee has 4+ pitting edema of lower extremities with chronic ulcers being treated 
with debridement, limb elevation, compression, therapy, and general wound care. Cellulitis/osteomyelitis was 
diagnosed. A request was made for PalinGen skin substitute. However, the provided documentation did not 
show objective evidence of a failure of conservative treatments, resolution of infection, or evidence of 
sufficient circulation of the lower extremities to be a candidate for grafting. Therefore, the PalinGen skin 
substitute will be considered not medically necessary at this time based on the provided recent documentation.  
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve PalinGen skin substitute.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device, and a pneumatic appliance 
provided on January 26, 2023. 
 
You asked the Plan to pay for a pneumatic compression device, and a pneumatic appliance. You say that these 
items were 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 a pneumatic 
compression device, and a pneumatic appliance provided on January 26, 2023.