Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the medical supplies provided on January 
26, 2023. 
 
You asked the Plan to waive the coinsurance for the medical supplies. You say that you have not been charged 
for this in the past. 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 in-network durable medical equipment and related supplies. 
 
You have been asked to pay 20% coinsurance for the medical supplies. This item/service falls within the in-
network durable medical equipment and related 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. The total you owe is $23 ($115 allowed amount x 20% = 
$23). Therefore, we decided that the Plan does not have to waive the coinsurance for the medical supplies 
provided on January 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service March 10, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this should be paid for. The Plan denied 
your request. The Plan says procedure code 99100 is considered bundled and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service March 10, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to waive the cost sharing for the lab services, the spine x-ray, the chest x-ray, and 
the physical therapy evaluation provided by an in-network provider on March 5, 2023, and March 6, 2023. 
 
You asked the Plan to waive the cost sharing for the lab services, the x-rays, and the physical therapy 
evaluation. You say that you believe that these services were medically necessary. The Plan denied your 
request. The Plan says that 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 enrollees pay a $0 copayment for in and out-of-network lab services, basic 
radiological services, and physical therapy services provided in all places of service. 
 
The Plan says you must pay a cost share of $46.53 for the lab services, the x-rays, and the physical therapy 
evaluation. Based on the Plan contract, however, you cannot be asked to pay any cost sharing for the lab 
services, the x-rays, and the physical therapy evaluation. Therefore, we decided that the Plan has to waive the 
cost sharing for the lab services, the spine x-ray, the chest x-ray, and the physical therapy evaluation provided 
by an in-network provider on March 5, 2023, and March 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for resin-based composite - three surfaces, posterior tooth 
#14 (D2393) provided on March 13, 2023. 
 
You asked the Plan to pay more for the resin-based composite - three surfaces, posterior. You say that you are 
enrolled in the dental option and the procedure was performed by an in-network provider. The Plan denied your 
request. The Plan says the benefit was paid at the least costly method of treatment, and you are responsible for 
the remaining balance. 
 
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.  This benefit includes coverage for fillings once every 24 months per surface, per tooth. White fillings on 
posterior teeth will be processed as a silver filling and the patient is responsible for up to the contracted fee. 
You pay 20% coinsurance for Class 2 Basic services. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage that covers the requested resin-based 
composite - three surfaces, posterior, the Plan processes it as a silver filling and you are responsible up to the 
contracted fee. You are responsible for the difference between the two allowed amounts The least costly 
method of treatment was amalgam-three surfaces, primary or permanent (D2160) with an allowed cost of 
$136.00. As you are responsible for a 20% coinsurance for fillings, 20% of $136.00 = $27.20. Because the Plan 
paid on the least costly method of treatment, you are responsible for the difference between the two allowed 
amount of $186.00-$136.00 = $50.00. This $50.00 was added to the $27.20 which you are responsible for, 
which is the total cost of $77.20 ($50.00 + 27.20 = $77.20) for the filling you received  Therefore, we decided 
that the Plan does not have to pay more for resin-based composite - three surfaces, posterior tooth #14 (D2393) 
provided on March 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies.  
 
You asked the Plan to pre-approve incontinence supplies. You say that the enrollee suffers from urge 
continence. This creates multiple difficulties for the enrollee including the cost of supplies and embarrassment 
of accidents while in public. The Plan denied your request. The Plan says this item is not covered by your Plan. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services related to end-stage renal disease (ESRD) 
provided on October 7, 2022, to October 14, 2022. 
 
You asked the Plan to pay for the ESRD-related services. The Plan denied your request. The Plan says 
Medicare does not separately pay for ESRD-related services. 
 
The Plan must follow Medicare rules. Medicare rules state that ESRD services are not separately payable. 
Providers should bill the facility directly for services as they are considered part of the composite rate. No other 
payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for the services 
related to end-stage renal disease (ESRD) provided on October 7, 2022, to October 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical nutrition therapy. 
 
You asked the Plan to pre-approve medical nutrition therapy services. You say that the enrollee's physician 
recommended weight loss. The Plan denied your request. The Plan says the enrollee does not have diabetes or 
renal disease to warrant coverage for medical nutrition therapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the 
Plan does not have to pre-approve medical nutrition therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint injection.  
You asked the Plan to pre-approve a sacroiliac joint injection. The Plan denied your request. The Plan says  a 
sacroiliac joint 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 a sacroiliac joint injection. Our 
reviewer says that the enrollee does not meet the coverage criteria. Our physician reviewer found that the LCD 
requires 3 physical exams and a sacroiliac joint test to be documented, however there is only one listed. 
Therefore, the requested sacroiliac joint injection 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 a sacroiliac joint injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a sacroiliac joint injection.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services for date of service November 6, 
2022, to December 1, 2022. 
 You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is October 7, 2022. The NOA was not received by the Plan until December 
30, 2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services for 
date of service November 6, 2022, to December 1, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that  it is medically necessary.  The Plan 
denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and is currently 
unstable for transfer 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 that there is no documentation provided indicating medical necessity for admission to 
a LTACH. The enrollee is receiving appropriate care at the present acute care facility. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where the enrollee is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at 
the health care setting being offered by the health plan. The requested LTACH services are not medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished 
safely and effectively only on an inpatient basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve single photon emission computed tomography (SPECT) 
scan (78803). 
 
You asked the Plan to pre-approve a SPECT scan. You say that this is medically necessary. The Plan denied 
your request. The Plan says the request does not meet the Medicare of health plan coverage criteria. 
 
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 a SPECT scan. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee does not readily have a condition for which the NCD supports provision of a DaT 
scan. Furthermore, DaT scans are primarily used to differentiate between essential tremor and Parkinson's 
disease. The enrollee's symptoms in this case were not otherwise readily parkinsonian and were more 
consistent with their neuropathy. 
 
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 SPECT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve single photon emission computed tomography (SPECT) scan (78803).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three Cystourethroscopies (52287 x3) and three Botox 
injections (J0585 x3). 
 
You asked the Plan to pre-approve the Cystourethroscopies and Botox injections. The Plan denied your request. 
The Plan says Botox is not a proven treatment for the enrollee's condition (stress incontinence). The Plan also 
says there are not enough medical studies to show this works well for the enrollee's condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
 
 
 
 
 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 Cystourethroscopies and Botox 
injections. Our reviewer says that this request is not medically necessary. Our physician reviewer found that 
Botox is not FDA-approved for treatment of stress urinary incontinence. The use of Botox for treatment of 
stress urinary incontinence is not supported by one of the major drug compendia or by clinical research that 
appears in a Centers for Medicare and Medicaid Services (CMS) approved medical journal. Our reviewer 
found that the use is not indicated, supported or recommended in any of the compendia. Our physician reviewer 
also found that the use of Botox for treatment of stress urinary incontinence does not meet Medicare criteria for 
safe and effective and otherwise reasonable and necessary for this enrollee.  
 
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 Cystourethroscopies and Botox injections have not been met. Therefore, we 
decided that the Plan does not have to pre-approve three Cystourethroscopies (52287 x3) and three Botox 
injections (J0585 x3).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator implant.  
You asked the Plan to pre-approve a spinal cord stimulator implant.. You say that after the procedure was 
performed the enrollee was provided with 100% pain relief. The Plan denied your request. The Plan says a 
spinal cord stimulator implant 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 an epidural neurostimulator. Our 
reviewer says that the enrollee does not meet the coverage criteria. Our physician reviewer found that the 
enrollee is morbidly obese and has chronic lock back pain. The enrollee also takes Gabapentin and 
Hydrocodone for pain and has tried message therapy. Also, the enrollee has had a phycological evaluation and 
was cleared for a spinal cord stimulator implant. However, the enrollee does not have an evidence-based 
indication for a spinal cord stimulator and has not had any physical therapy. 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 an epidural neurostimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a spinal cord stimulator implant.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation to be provided by an out-of-network 
(OON) oral surgeon.  
 
You asked the Plan to pre-approve the physician service. You say that you are in pain. You say that you cannot 
eat. The Plan denied your request. The Plan says there are equally qualified network providers available to 
provide this service. 
 
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 consultation to be provided by an out-of-network (OON) oral surgeon.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99152 billed for date of service December 14, 2022. 
 
You asked the Plan to pay for code 99152. You say that the medical records support payment of this code The 
Plan denied your request. The Plan says billed code 99152 is not supported by the medical record. The Plan 
also says that codes 36561, 76937 and 77001 have been paid and are not at issue. 
 
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 99152 is Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patients level of consciousness and physiological status; initial 15 minutes of intra-service time, patient age 
5 years or older. 
 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 code 99152. Our reviewer says that code 99152 is not 
supported by the medical record. Our reviewer found the documentation does not contain required elements of 
the code, such as time spent at the patient's bedside and a trained, independent observer. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99152 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99152 billed for date of service December 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic manipulative treatment provided on March 20, 
2023. 
 
You asked the Plan to pay for chiropractic manipulative treatment. You say that you were not aware that the 
provider was out-of-network. 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 chiropractic 
manipulative treatment provided on March 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device and accessory provided 
on January 13, 2023. 
 
You asked the Plan to pay for the pneumatic compression device and accessory. The Plan denied your request. 
The Plan says this is not payable outside the home. 
 
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 and accessory provided on January 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a binaural dispensing fee (V5160) and a binaural, digital 
hearing aid (V5261) provided on March 13, 2023. 
 
You asked the Plan to pay for a binaural dispensing fee (V5160) and a binaural, digital hearing aid (V5261). 
You say that your hearing has had a significant decrease. The Plan denied your request. The Plan says hearing 
aids must be purchased through the Plan hearing. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only the hearing aids are purchased inside of the Plan's hearing network.  
 
 
  We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of a binaural dispensing fee (V5160) and a binaural, digital hearing aid (V5261) have not been met. 
Therefore, we decided that the Plan does not have to pay for a binaural dispensing fee (V5160) and a binaural, 
digital hearing aid (V5261) provided on March 13, 2023.