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

 
We decided that the Plan does not have to pay for wound care services provided on January 12, 2023. 
 
You asked the Plan to pay for wound care services. You say that these services 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 wound care services 
provided on January 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the health club membership (S9970) and sales tax (S9999) 
provided from September 6, 2022, to January 31, 2023, at a non-participating location. 
 
You asked the Plan to pay for the health club membership and sales tax. You say that it was recommended that 
you go to the non-participating provider for bone health therapy as you are unable to tolerate osteoporosis 
medications. You also say that programs like the Plan's fitness program do not address your specific bone 
health needs, and you would like to be reimbursed for these sessions. The Plan denied your request. The Plan 
says the provider is not a participating health club with the Plan's fitness program. The Plan also says that 
health club membership (S9970) and sales tax (S9999) are procedure codes that are not covered by Medicare. 
 The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan offers a 
supplemental fitness benefit through the Plan's fitness program. 
 
The Plans rules for coverage of gym benefits have not been met because the contract clearly states that the 
benefit is limited to health clubs that participate with the Plan's fitness program. There is no coverage for health 
clubs that do not participate. Therefore, we decided that the Plan does not have to pay for the health club 
membership (S9970) and sales tax (S9999) provided from September 6, 2022, to January 31, 2023, at a non-
participating location.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve venography, extremity, unilateral, radiological 
supervision and interpretation (75820), venography, caval, inferior, with serialography, radiological 
supervision and interpretation (75825), and selective catheter placement, venous system; first order branch 
(36011). 
 
You asked the Plan to pre-approve venography, extremity, unilateral, radiological supervision and 
interpretation (75820), venography, caval, inferior, with serialography, radiological supervision and 
interpretation (75825), and selective catheter placement, venous system; first order branch (36011).. You say 
that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been 
established. Therefore, coverage criteria have not been met. 
 
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 venography, extremity, unilateral, 
radiological supervision and interpretation (75820), venography, caval, inferior, with serialography, 
radiological supervision and interpretation (75825), and selective catheter placement, venous system; first order 
branch (36011).. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the documentation does not support the medical 
necessity of the treatments in question.  It is documented that the enrollee's symptoms have improved 
significantly. There is no documentation of whole leg swelling and no evidence of proximal venous obstruction 
on noninvasive studies.  In the absence of significant symptoms and in the absence of objective findings 
suggestive of proximal venous occlusive disease, medical necessity is not supported. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of venography, extremity, unilateral, radiological supervision and interpretation 
(75820), venography, caval, inferior, with serialography, radiological supervision and interpretation (75825), 
and selective catheter placement, venous system; first order branch (36011). have not been met. Therefore, we 
decided that the Plan does not have to pre-approve venography, extremity, unilateral, radiological supervision 
and interpretation (75820), venography, caval, inferior, with serialography, radiological supervision and 
interpretation (75825), and selective catheter placement, venous system; first order branch (36011).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a skilled nursing facility visit provided on December 01, 
2022. 
 
You asked the Plan to pay for a skilled nursing facility visit. You say that this was medically necessary and 
should be covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a skilled nursing facility 
visit provided on December 01, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on January 23, 
2023. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the services 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 subsequent nursing 
facility care provided on January 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic radiology provided on February 06, 2023. 
 
You asked the Plan to pay for diagnostic radiology. You say that the services 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 diagnostic radiology 
provided on February 06, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames (V2020 x2) and progressive lenses (V2781 x2) 
purchased on January 14, 2023 from an out-of-network (OON) provider. 
 
You asked the Plan to pay for the frames and progressive lenses. You say that after looking at those provided 
for in-network, it was by far cheaper to purchase eyeglasses from an OON provider. You also say that you are 
requesting reimbursement for the balance of $179.96, or whatever the percentage of vision costs is 
reimbursable to this amount. The Plan denied your request. The Plan says you used your yearly flex allowance 
in the amount of $500.00 leaving a total responsibility of $179.96 ($679.96 - $500.00 = $179.96). The Plan 
also says the remaining $179.96 will not be covered, as research shows that these glasses were purchased from 
a vendor who is not a Plan approved provider. 
 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 these services when services are rendered by a contracted provider. 
 
We looked at the file and the Plan's rules. The record shows that you used your entire $500 balance from your 
Flex Account on this purchase, and because the services were provided OON, the Plan will not pay for the 
services. Based on this information, we decided that the Plan's rules for coverage of the frames and progressive 
lenses have not been met. Therefore, we decided that the Plan does not have to pay for the frames (V2020 x2) 
and progressive lenses (V2781 x2) purchased on January 14, 2023 from an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a crown (D2751) for tooth number 15. 
 
You asked the Plan to pre-approve the dental services. You say that the crown is loose, and food gets under the 
crown when you eat. The Plan denied your request. The Plan says that it is not medically necessary to replace 
the crown on your tooth. 
 
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. The Plan covers the dental 
services when the services are medically necessary and reasonable. 
 
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 dental services. Our reviewer says 
that the criteria for coverage for a replacement crown has been met. Our physician reviewer found that the 
documentation indicates that the crown in place is loose and defective with open margins and fractured 
porcelain. This crown has been in place for 13 years. A replacement crown is medically reasonable and 
necessary to provide adequate masticatory function. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have been met. Therefore, we decided that the Plan has to 
pre-approve a crown (D2751) for tooth number 15.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mobile cardiac outpatient telemetry (MCOT) monitor. 
 
You asked the Plan to pre-approve MCOT monitor. 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 cardiac event monitors are covered when certain 
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 MCOT monitor. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is no supportive evidence that the 
ordering practitioner documented any standard, non-MCOT, ambulatory electrocardiogram (ECG) monitoring. 
In summary, there is insufficient documentation to support the medical necessity for an MCOT monitor in this 
enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MCOT monitor have not been met. Therefore, we decided that the Plan does 
not have to pre-approve mobile cardiac outpatient telemetry (MCOT) monitor.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical removal of excess skin of both arms. 
 
You asked the Plan to pre-approve surgical removal of excess skin of both arms. You say that this excess skin 
is causing you pain and you are experiencing repeated tears and infections in this tissue. The Plan denied your 
request. The Plan says the requested procedure is cosmetic in this case and is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 surgical removal of excess skin of both 
arms. Our reviewer says that the requested service is not medically necessary. Our reviewer found the record 
indicates that you have had significant weight loss following bariatric surgery. The record provided does not 
document that the requested service is required for the prompt repair of accidental injury or to improve the functioning of a malformed body member. The record provided does not establish the medical necessity and 
reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria 
are not satisfied. The requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of surgical removal of excess skin of both arms have not been met. Therefore, we 
decided that the Plan does not have to pre-approve surgical removal of excess skin of both arms.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an incisional biopsy of oral tissue-soft (D7286) provided on 
November 29, 2022. 
 
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 Plan benefits. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
 
  The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for an incisional biopsy of oral 
tissue-soft (D7286) provided on November 29, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided from February 7, 2022, 
through February 11, 2022. 
 
You asked the Plan to pay for the medical services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the enrollee confirmed that they have not traveled to New Jersey, does not reside in 
that state, and have no received the services billed to the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
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 the medical services have been met. 
The provider did not confirm that the insurance belonged to the patient, so the documentation does not show 
that payment is due for the services. Therefore, we decided that the Plan does not have to pay for the medical 
services provided from February 7, 2022, through February 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mastectomy for gynecomastia (19300), suction assisted 
lipectomy; trunk (15877) and nipple/areola reconstruction (19350). 
 
You asked the Plan to pre-approve a mastectomy, lipectomy and nipple/areola reconstruction. You say that this 
surgery is needed for an abnormality. The Plan denied your request. The Plan says there is no documentation of 
the grade level of gynecomastia or abnormal breast development with skin redundancy. The documentation 
does not show that you have had gynecomastia for two years. 
 
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 mastectomy, lipectomy and 
nipple/areola reconstruction. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found that the case file does not contain 
documentation of Grade III and IV gynecomastia. Severe hypertrophy of breast tissue with ptosis were not 
documented. There is no documentation of abnormal breast development with redundancy. The case file does 
not contain documentation of the duration of excess breast tissue, nor does it document any functional 
impairment. As the mastectomy for gynecomastia does not meet criteria for coverage, the requested 
nipple/areola reconstruction is not covered. Additionally, the clinical record in this case does not clearly 
demonstrate medical necessity for the lipoma or nodule removal. 
 
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 mastectomy, lipectomy and nipple/areola reconstruction have not been met. 
Therefore, we decided that the Plan does not have to pre-approve mastectomy for gynecomastia (19300), 
suction assisted lipectomy; trunk (15877) and nipple/areola reconstruction (19350).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 22, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting.  Therefore, we decided that 
the Plan does not have to pay for lab services provided on December 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a push handle for a wheelchair (K0108). 
 
You asked the Plan to pre-approve the push handle. You say that this accessory is medically necessary. The 
Plan denied your request. The Plan says this item is not primarily medical in nature and is non-covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
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.  Therefore, we 
decided that the Plan does not have to pre-approve a push handle for a wheelchair (K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care, and an inhalation treatment provided on 
January 30, 2023. 
 
You asked the Plan to pay for nursing facility care, and an inhalation treatment. You say that the enrollee could 
not choose an in-network provider. 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 nursing facility care, and 
an inhalation treatment provided on January 30, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service February 10, 
2023.  
 
You asked the Plan to pay for procedure code 76641. You say that this should be paid for. The Plan denied 
your request. The Plan says the number of units billed exceeds the maximum allowed.   
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service February 10, 2023.