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

 
We decided that the Plan does not have to pay for massage therapies provided on February 6, 2023, to August 
1, 2023. 
 
You asked the Plan to pay for massage therapies. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says therapeutic massage is not covered under any 
condition. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pay for massage therapies provided on February 6, 2023, to August 1, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infrared therapy provided from June 23, 2023, to June 27, 
2023. 
 
You asked the Plan to pay for infrared therapy. You say that you are requesting the claim be reviewed and 
reprocessed for payment. The Plan denied your request. The Plan says the service performed is considered not 
reasonable and necessary by Medicare and is excluded from coverage. The Plan must follow Medicare rules. Medicare rules say that infrared therapy is not covered.  
 
We looked at the file and Medicare rules. Medicare does not cover the requested service at this time. Based on 
this information, we decided that Medicare rules for coverage of infrared therapy have not been met. Therefore, 
we decided that the Plan does not have to pay for infrared therapy provided from June 23, 2023, to June 27, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 12, 2023. 
 
You asked the Plan to pay for the laboratory services. 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 laboratory services 
provided on July 12, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the injection services provided on July 26, 
2023. 
 
You asked the Plan to waive the copayment for the injection services. You say that the copayment is too high. 
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 $300 
copayment for outpatient hospital services. 
 
You have been asked to pay a $300 copayment for the injection services. This item/service falls within the 
outpatient hospital services benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, since the allowed amount is less than the standard copayment, you only owe 
$295. Therefore, we decided that the Plan does not have to waive the copayment for the injection services 
provided on July 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve a portable oxygen concentrator. 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 home oxygen therapy and oxygen equipment is 
reasonable and necessary when specific criteria are met. 
 
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 portable oxygen concentrator. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found a portable oxygen 
concentrator is not medically necessary because Medicare criteria are not met. You were prescribed a stationary 
oxygen concentrator and portable E-tanks. You are unable to lift the tanks or handle them when being 
transported for medical visits. However, there is no documentation in the medical record that the oxygen 
saturation can be maintained greater than 91% while using an oxygen conserving device with a flow rate of 1 to 
4 L/min. 
 
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 portable oxygen concentrator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a portable oxygen concentrator (E1392).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the retainer crowns - porcelain/ceramic (D6740) provided on 
January 18, 2023. 
 
You asked the Plan to pay for the retainer crowns. You say that these services were medically necessary after 
you suffered a fall. The Plan denied your request. The Plan says this service is not a covered expense under 
your dental plan. 
 
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 services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the retainer 
crowns - porcelain/ceramic (D6740) provided on January 18, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for frames (V2020) and lenses (V2100) provided on August 22, 2023. 
 
You asked the Plan to pay for frames and lenses. You say that you would like the Plan to take care of your eye 
doctor as you have $150 coverage under the Plan vision benefit. The Plan denied your request. The Plan says 
that this benefit has been exhausted. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers $150 for eyeglasses or contact lenses every year. 
 
We looked at the file and the Plan's rules. The Plan rules say that the Plan covers up to $150 for eyeglasses or 
contact lenses every year. The Plan rules also say that after the Plan paid benefits for eyeglasses (lenses and 
frames) or contact lenses, you are responsible for the remaining cost. The record clearly shows that the Plan 
pays $150 for eyewear each year. The record also clearly shows that the Plan did not pay $150 for the eyewear, 
they only paid $105. Based on this information, we decided that the Plan's rules for coverage of frames and 
lenses have been met. Therefore, we decided that the Plan has to pay for frames (V2020) and lenses (V2100) 
provided on August 22, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cold pad with pump (E0218) provided on May 15, 2023 to 
June 7, 2023. 
 
You asked the Plan to pay for the cold pad with pump. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that a fluid circulating cold pad with pump (E0218) 
will be denied as not reasonable and necessary.  
 
We looked at the file and Medicare rules. This item is non-covered under Medicare rules. Based on this 
information, we decided that Medicare rules for coverage of the cold pad with pump have not been met. 
Therefore, we decided that the Plan does not have to pay for a cold pad with pump (E0218) provided on May 
15, 2023 to June 7, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for portable hand x-rays provided on May 13, 2023. 
 
You asked the Plan to pay for portable hand x-rays. You say that there was no time 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 portable hand x-rays 
provided on May 13, 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 17, 2023, to April 20, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 
copayment for inpatient hospital care. 
 
You have been asked to pay a $295 copayment for the inpatient hospital stay. This item/service falls within the 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 $885 for the inpatient hospital stay ($295 copayment 
x 3 days = $885). 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 17, 2023, to April 
20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dentoalveolar structures (41899). 
 
You asked the Plan to pre-approve the dental service. You say that the requested dental service is medically 
necessary. The Plan denied your request. The Plan says the denial for authorization for this service is correct, 
because there was no documentation from 
the enrollee's primary insurance. 
  The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan directed the 
provider to send the requested dental service to the primary insurer. As the secondary insurer, the Plan cannot 
be held responsible for the dental service until the primary insurer has denied the service or only partially 
approved the service. Therefore, we decided that the Plan does not have to pre-approve the dentoalveolar 
structures (41899).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20551 billed for August 2, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 20551 is 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 20551 is injection(s); single tendon origin/insertion. 
 
We find that CPT code 20551 is not supported in the medical record. Specifically, the records show that a left 
piriformis injection under fluoroscopic guidance was performed and there is a more appropriate code for the 
services. Based on this information, we decided that Medicare rules for coverage of these services have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure code 20551 billed for August 
2, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a portable chest x-ray provided on March 22, 2023, to July 
26, 2023. 
 
You asked the Plan to pay for a portable chest x-ray. You say that there was no time 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 chest x-ray 
provided on March 22, 2023, to July 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture services to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve acupuncture services. You say that you are suffering from swelling and pain 
in your hand from extremely debilitating arthritis. You say that you feel like these first sessions have helped 
you a lot and wish to continue with the current provider. The Plan denied your request. The Plan says that 
acupuncture services are available in network. 
 
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 
acupuncture services to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the semi-precision abutment  placement (D6191), surgical 
removal of implant body (D6100), and intravenous moderate (conscious) sedation/analgesia- first 15 minutes  
(D9239) provided on June 14, 2023. 
 
You asked the Plan to pay for the dental services. You say that these services should be covered at 100% and 
you should be reimbursed. The Plan denied your request. The Plan says these services are not a covered 
expense under the plan. 
 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 services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the semi-
precision abutment  placement (D6191), surgical removal of implant body (D6100), and intravenous moderate 
(conscious) sedation/analgesia- first 15 minutes  (D9239) provided on June 14, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a group 3 power wheelchair with multiple power options and 
accessories (E0955, E1002, E1012, E1028, E2311, E2361, E2603, K0856). 
 
You asked the Plan to pre-approve the group 3 power wheelchair with multiple power options and accessories. 
You say that this wheelchair is medically necessary. The Plan denied your request. The Plan says that the 
requested wheelchair exceeds the enrollee's needs. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to a neurological condition, Myopathy, or congenital 
skeletal deformity. A group 3 wheelchair with multiple power options is covered when the enrollee also needs 
a power tilt and recline seating system or the beneficiary uses a ventilator which is mounted on the wheelchair. 
 
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 group 3 power wheelchair with 
multiple power options and accessories. Our reviewer says that the requested power wheelchair and features 
are medically necessary. Our physician reviewer found the enrollee is non-ambulatory and cannot use a cane or 
walker for mobility. She cannot functionally propel a manual wheelchair due to upper extremity weakness. The 
patient requires a power wheelchair for mobility and accomplishing their daily activities. She is noted to have 
2/5 motor strength in the upper extremities as well as impaired sensation, and cannot perform pressure relief 
independently. The enrollee requires power tilt for pressure relief. She does have lower extremity spasticity that 
requires positioning and a power articulating foot platform. The patient cannot sit independently without 
support due to her stroke, impaired trunk control, spasticity, and hemiplegia. She requires the more advanced 
positioning and seating that is provided by the requested power wheelchair. 
 
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 group 3 power wheelchair with multiple power options and accessories have 
been met. Therefore, we decided that the Plan has to pre-approve a group 3 power wheelchair with multiple 
power options and accessories (E0955, E1002, E1012, E1028, E2311, E2361, E2603, K0856).  
 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 the extra spinal chiropractic manipulative treatment provided 
by a chiropractor on July 25, 2023. 
 
You asked the Plan to pay for the extra spinal chiropractic manipulative treatment. You say that you were told 
that you would only be responsible for a $20 deductible for future visits after the first initial visit. The Plan 
denied your request. The Plan says the only covered chiropractic service is manual manipulation of the spine. 
 
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 records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the extra spinal chiropractic manipulative treatment provided by a 
chiropractor on July 25, 2023.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for an emergency department visit (procedure code 99285) provided on 
December 7, 2022. 
 
You asked the Plan to pay for an emergency department visit (procedure code 99285). You say that procedure 
code 99285 is appropriate based on the services performed. The Plan denied your request. The Plan says that 
procedure code 99284 is more appropriate for the services rendered. 
 
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 an emergency department visit (procedure code 99285). Our 
reviewer says that the services at issue in this case are supported by the medical records. Our reviewer found 
that a medically appropriate history and physical were performed. Medical records support a high level of 
decision making. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an emergency department visit (procedure code 99285) have been met. 
Therefore, we decided that the Plan has to pay for an emergency department visit (procedure code 99285) 
provided on December 7, 2022.  
 
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.