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

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance image (MRI) 
provided on January 21, 2023. 
 
You asked the Plan to waive the copayment for a magnetic resonance image (MRI). You say that you were told 
to get the procedure done at a specific facility and now you are receiving a bill. 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 $275 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $275 copayment for a magnetic resonance image (MRI). This item/service falls 
within the outpatient diagnostic test 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 $216.51, which is less than the standard copayment for an 
MRI. Therefore, we decided that the Plan does not have to waive the copayment for a magnetic resonance 
image (MRI) provided on January 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87641, and 87653 billed for date of 
service December 9, 2022. 
 
You asked the Plan to pay for procedure codes 87481, 87641, and 87653. You say that you disagree with the 
denial. The Plan denied your request. The Plan says payment for codes 87481, 87641, and 87653 is bundled 
into payment for code 87801. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that codes 
87481, 87641, and 87653 are column II codes to column I code 87801. This claim has not been billed with an 
appropriate modifier to bypass the edit. The -XU modifiers are not supported as a separate and distinct 
procedural service. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 87481, 87641, and 87653 billed for date of 
service December 9, 2022.
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) 
device. 
 
You asked the Plan to pre-approve a CGM. You say that the enrollee has dementia and refuses to take her 
insulin. The Plan denied your request. The Plan says the medical criteria for a CGM have not been met. 
 
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 provided does not indicate that the enrollee uses 
insulin. Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose 
monitor (CGM) device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup services (D2950) provided on March 8, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for core 
buildup services (D2950) provided on March 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodontal maintenance procedure and periodic oral 
evaluation (D4910, D0120) provided on February 27, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
periodontal maintenance procedure and periodic oral evaluation (D4910, D0120) provided on February 27, 
2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paramedic intercept services.  
 
You asked the Plan to pay for the paramedic intercept services. You say that you did not have any say in who 
came to pick you up. You also say that you do not feel that you should have to pay for the paramedic intercept 
services. The Plan denied your request. The Plan says this item is not a covered benefit.  
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. 
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as 
defined above. It is noted that the only State in which these criteria are met is New York. 
 
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural 
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the 
paramedic intercept services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for an ER visit and self-administered drugs provided 
from October 26, 2022, to October 28, 2022. 
 
You asked the Plan to waive the cost for an ER visit and self-administered drugs. You say that you feel the cost 
applied is too high and you disagree with the copayment applied for the emergency room visit. The Plan denied 
your request. The Plan says this cost 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 $120 
copayment for emergency care and self-administered drugs are not covered as a medical benefit under the Plan.  
 
You have been asked to pay $1,121 for an ER visit and self-administered drugs. This total includes a $120 
copayment for an ER visit and $1,001 for self-administered drugs. An ER visit falls within the emergency care 
benefit category. The rules say that Medicare Part B generally does not pay for self-administered drugs. The 
self-administered drugs requested here are not among the types which are covered by Medicare Part B. 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 cost for an ER visit and self-administered drugs provided from October 26, 
2022, to October 28, 2022.  
 
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (Q5001, G0151, 31C31, G0299) 
provided on December 13, 2022, to January 11, 2023, by a Medicare opt-out provider. 
 
You asked the Plan to pay for the home health services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
provided by a facility that does not participate with Medicare. 
 
 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 home health services (Q5001, G0151, 31C31, 
G0299) provided on December 13, 2022, to January 11, 2023, by a Medicare opt-out provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Lasik surgery. 
 You asked the Plan to pre-approve the Lasik surgery. You say that the surgery should be covered under your 
flex card.  The Plan denied your request. The Plan says the service is not a covered benefit. 
 
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 does not cover this benefit. 
 
We looked at the file and the Plan's rules. Specifically, the service is not a covered benefit. Based on this 
information, we decided that the Plan's rules for coverage of the Lasik surgery have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the Lasik surgery.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on September 19, 2022, billed 
with code 37253 x4. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says records do not support the service billed. 
 
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 37253 x4 is Intravascular ultrasound (noncoronary 
vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and 
interpretation; each additional noncoronary vessel. 
 
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 imaging services provided. Our reviewer says that 
documentation does not support the number of units billed. Our reviewer found that although the procedure 
report describes Intravascular ultrasound, the units billed cannot be verified. 
 
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 imaging services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for imaging services provided on September 19, 2022, billed with code 37253 x4.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit provided on February 06, 2023. 
 
You asked the Plan to pay for home visit. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for home visit provided on 
February 06, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paramedic intercept services.  
 
You asked the Plan to pay for the paramedic intercept services. You say that you are asking for the advance life 
support services to be paid. The Plan denied your request. The Plan says this item is not a covered benefit. 
 The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. 
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as 
defined above. It is noted that the only State in which these criteria are met is New York. 
 
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural 
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the 
paramedic intercept services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided from December 27, 
2022, to January 27, 2023. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you feel that since there are separate 
bills for two different years, the benefits should be renewed for the new year. 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 $0 
copayment for days 1 to 20 and a $196 copayment per day for days 21 to 100 for SNF care.  
 
 
  You have been asked to pay $980 for a SNF stay ($196 per day x 5 days = $980). This item/service falls within 
the SNF 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 a SNF stay provided from 
December 27, 2022, to January 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical placement of implant body (D6010) and 
surgical access to an implant body (D6011). 
 
You asked the Plan to pre-approve the dental services. You say that the previous dental implant procedure did 
not work. You are having a very difficulty with quality of life because your previous dentist removed your 
entire upper denture. The Plan denied your request. The Plan says your benefit for the requested item or service 
has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted in 2021. Therefore, we decided that the 
Plan does not have to pre-approve the surgical placement of implant body (D6010) and surgical access to an 
implant body (D6011).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bifocal lenses and the frames provided on February 6, 
2023. 
 
You asked the Plan to pay for the bifocal lenses and the frames. You say that you have always had 
polycarbonate lenses because you are legally blind in one eye and have glaucoma. The Plan denied your 
request. The Plan says the 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 one pair of eyeglasses per calendar year. 
 
We looked at the file and the Plan's rules. Specifically, the Plan paid for one pair of frames (claim number 
112394058200) on February 6, 2023, which exhausted the benefit. Based on this information, we decided that 
the Plan's rules for coverage of the bifocal lenses and the frames have not been met. Therefore, we decided that 
the Plan does not have to pay for the bifocal lenses and the frames provided on February 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5261) purchased on 
October 26, 2022. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says these items are not payable as 
they were purchased from an out-of-network provider.  
 
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 when purchased from the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract states that hearing aids are covered 
only when purchased from the Plans select hearing aid provider. However, the hearing aids in this case were 
purchased from an out-of-network provider. Therefore, we decided that the Plan does not have to issue 
reimbursement for the hearing aids (V5261) purchased on October 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the stab phlebectomies of non-saphenous varicosities. 
 
You asked the Plan to pre-approve the stab phlebectomies. You say that the enrollee suffers from swelling and 
pain in the legs. You say that the enrollee has tried compression therapy for over three months. You say that the 
enrollee elevates the legs every night, engages in moderate to strenuous exercises three days a week and daily 
walking. You also say that the enrollee is in good shape and does not require weight loss. The Plan denied your 
request. The Plan says saphenous reflux has not been eliminated. The Plan says measurement of the other 
varicosities was not documented. The Plan also says that the services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that the treatments of the tributary veins will be 
considered medically necessary if saphenous reflux is not present or already successfully eliminated, the veins 
are greater than 4 mm in diameter and if the patient remains symptomatic after a six-week trial of conservative 
therapy. 
 
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 stab phlebectomies. Our reviewer 
says that the requested stab phlebectomies are not medically necessary. Our physician reviewer found or 
tributary treatment such as stab phlebectomy to be considered medically necessary per coverage criteria, there 
needs to be persistent significant symptoms following successful treatment of truncal (saphenous) reflux with 
these symptoms existing more than 6 weeks after the reflux was treated and despite conservative efforts.  
Additionally, the veins to be treated need to be at least 4 mm in diameter (this condition not met as size of 
venous tributaries not provided). The reviewer found that since the enrollee has not yet undergone saphenous 
vein reflux treatment, the above criteria have not been met. The Health Plan does not provide for simultaneous 
saphenous reflux treatment and tributary treatment. A rationale for this is that many experience satisfactory 
relief with the truncal intervention alone. Coverage criteria also require that the symptoms in question be 
attributable to the veins planned for treatment.  It is not possible to attribute the enrollees leg symptoms to the 
varicose veins without an assessment of lower extremity arterial perfusion. Therefore, the reviewer found that 
the requested stab phlebectomies are not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the stab phlebectomies have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the stab phlebectomies of non-saphenous varicosities.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve True Metrix glucose test strips. 
 
You asked the Plan to pre-approve True Metrix glucose test strips. You say that you do not agree with the 
denial of the requested item. The Plan denied your request. The Plan says only the preferred brand products 
listed in the EOC are covered.  
  The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for glucose test strips. Therefore, we decided that the Plan does not have to pre-approve True Metrix glucose 
test strips.