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

 
We decided that the Plan does not have to pay for the total hip arthroplasty (27130) provided on March 29, 
2023. 
 
You asked the Plan to pay for the surgical service. You say that the provider assisted the surgeon at their 
request. You also say that the assistant surgeon is required in the enrollee's state of residence and should be 
paid for their time. The Plan denied your request. The Plan says this provider is not eligible for payment. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for the total hip arthroplasty (27130) 
provided on March 29, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport, and ground mileage provided on April 18, 2023. 
 
You asked the Plan to pay for the ambulance service and ground mileage. You say that due to the enrollee's 
condition at the time of transport, any other means of transport would be unsafe.  The Plan denied your request. 
The Plan says the enrollee did not require the expertise of trained personnel or the equipment available only in 
an ambulance in order to effectuate a safe transport.  
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
 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 pay for the ambulance service and ground mileage. 
Our reviewer says that the ambulance service and ground mileage was not medically necessary. Our physician 
reviewer found the enrollee was transported from an acute care facility to a rehabilitation facility via stretcher. 
The record does not indicate that the enrollee's condition was such that other methods of transport, such as 
stretcher, are contraindicated or that the expertise, services and lifesaving equipment that only a fully equipped 
ambulance can provide was required. The elements of coverage criteria are not satisfied. 
 
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 ambulance service and ground mileage have not been met. Therefore, we 
decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport, 
and ground mileage provided on April 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve an office visit. You say that the services should be covered to keep disease 
under control. The Plan denied your request. The Plan says this is 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 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lift chair. 
 
You asked the Plan to pre-approve a lift chair. You say that you struggle to get up from your chair. The Plan 
denied your request. The Plan says the requested device is not medically necessary.  
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section 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 lift chair. Our reviewer says that the 
documentation does not support that the requested device is medically reasonable or necessary. Our physician 
reviewer found you neuropathy and arthritis. You have some difficulty rising from your recliner. While you 
have difficulty rising, you are still able to rise from your recliner. There is no evidence you are unable to stand 
from a chair. Therefore, you do not meet criteria for the requested device. 
 
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 lift chair have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a lift chair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the office visit provided by an in-network 
provider on May 16, 2023. 
 
You asked the Plan to waive the cost sharing for the office visit. You say that you think that you are being 
billed incorrectly. 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. Your 
contract with the Plan says that there is a $150 deductible which applies to the office visit, and that you must 
pay a 4% coinsurance for in and out-of-network services from a primary care provider or under certain 
circumstances, treatment by a nurse practitioner, physician's assistant, or other non-physician health care 
professional in a primary care providers office. You have been asked to pay a $65.13 deductible for the office visit. You have also been asked to pay a $0.79 
coinsurance for the office visit ($84.87 allowed amount - $65.13 deductible = $19.74) ($19.74 x .04 = $0.79 
rounded up). The item or service you asked the Plan to waive the cost sharing for falls within the 
physician/practitioner services, including doctors office visits benefit category. The Plan has followed 
Medicare rules by clearly disclosing in the contract that there is a $150 deductible which applies to 
physician/practitioner services, including doctors office visits. This cost sharing is a contractual obligation that 
had not been met at the time the office visit was provided on May 16, 2023. Therefore, we decided that the 
Plan does not have to waive the cost sharing for the office visit provided by an in-network provider on May 16, 
2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the revision of colostomy (44340) provided on April 5, 2023. 
 
You asked the Plan to pay for the surgical service. You say that the provider was requested to assist in this 
procedure by the primary surgeon due to being medically necessary. The Plan denied your request. The Plan 
says this provider is not eligible to receive payment. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for the revision of colostomy (44340) 
provided on April 5, 2023.
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  admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee is receiving the care needed in the current 
hospital and there is no need to transfer to the LTACH at this time. 
 
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 the enrollee is receiving appropriate care in current acute care setting as provided by 
the Plan. Documentation does not support that LTACH services are medically appropriate at this time. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the dental cleaning (D1110) and the periodic oral 
evaluation (D0120) provided on May 8, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider.  
 
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for the dental cleaning (D1110) and the periodic 
oral evaluation (D0120) provided on May 8, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 standard power wheelchair with multiple 
power options (K0861) and additional items and accessories (codes E2311, E2313, E2377, E2361, E1028, 
E1007, E2300, E2620, E0955 E1012, and E2607). 
 
You asked the Plan to pre-approve a Group 3 standard power wheelchair and additional items and accessories. 
You say that you would like this request to be reconsidered. The Plan denied your request. The Plan says the 
enrollee does not have a medical need for multiple power options included with a K0861 group 3 power 
wheelchair. The Plan also says an electronic connection, harness, expandable controller cannot be covered as it 
is not medically necessary to control the three requested power options through the joystick (drive interface). 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 PWC with multiple power options (such as 
code K0861) is covered if the criteria listed in the Medicare rules section of this letter are met. Medicare rules 
also say that if the PWC base is not covered, then related accessories will be denied. 
 
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 Group 3 standard power wheelchair 
and additional items and accessories. Our reviewer says that the enrollee does not meet the criteria for 
coverage. Our physician reviewer found the enrollee has had a stroke, but is able to feed themself, stand, and 
transfer independently. The enrollee has intact skin. Our reviewer also found that the enrollee is not at high risk 
for skin breakdown, use a catheter, have spasticity, or require alternative means of controlling the 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 a Group 3 standard power wheelchair and additional items and accessories have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 standard power 
wheelchair with multiple power options (K0861) and additional items and accessories (codes E2311, E2313, 
E2377, E2361, E1028, E1007, E2300, E2620, E0955 E1012, and E2607).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that you are experiencing intense headaches 
following a car accident. The Plan denied your request. The Plan says the criteria for coverage have not been 
met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found you are only noted to have "memory 
problems". There is a suggestion that these problems may be related to a concussion suffered in a motor vehicle 
accident. The records did not support a diagnosis of either AD or FTD, let alone both conditions. This service 
would not meet criteria for coverage. 
 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that the records provided support medical necessity. 
The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the member is only noted to have a 
reported diagnosis of AD. The records did not support that the diagnostic criteria for both AD and FTD had 
been met. This service would not meet criteria for coverage. 
 
 
  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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services coded as 99223 
performed on February 28, 2023.  
 
You asked the Plan to pay for 99223. You say that 99223 should be paid as billed because it is supported in the 
record. The Plan denied your request. The Plan says 99223 is denied because it is not supported in the record. 
 
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 99223 is initial hospital inpatient or observation care, per 
day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded. 
 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 pay for 99223. Our reviewer says that code 99223 
billed for date of service February 28, 2023, is not supported in the documentation. Our reviewer found the 
medical records submitted for review do not support a high level of medical decision-making, nor do they 
document at least 75 minutes of face-to-face or non-face-to-face time. 
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 99223 have not been met. Therefore, we decided that the Plan does not have to 
pay for evaluation and management services coded as 99223 performed on February 28, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that the records provided support medical necessity. 
The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the member is only noted to have a 
diagnosis of a mild cognitive impairment. The records did not support a diagnosis of either AD or FTD, let 
alone both conditions. This service would not meet criteria for coverage. 
 
 
  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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup, including any pins when required tooth 
(D2950) provided on May 23, 2023. 
 
You asked the Plan to pay for the core buildup. You say that the procedure is done as part of the process 
needed to get the bridge, so how could it not be covered. The Plan denied your request. The Plan says this 
service is 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 service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for core buildup, 
including any pins when required tooth (D2950) provided on May 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a diagnostic service consultation by a dentist of physician 
other than the requesting dentist or physician (D9310) provided on May 22, 2023. 
 
You asked the Plan to pay for a diagnostic service consultation by a dentist of physician other than the 
requesting dentist or physician (D9310). You say that you were told that your dental services were covered by 
insurance. The Plan denied your request. The Plan says there is no coverage for a diagnostic service 
consultation by a dentist of physician other than the requesting dentist or physician (D9310). 
 
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 
diagnostic service consultation by a dentist of physician other than the requesting dentist or physician (D9310) 
provided on May 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided in the Republic of North Macedonia 
on October 4, 2022. 
 
You asked the Plan to pay for the dental services. You say that the procedures were very professional and a lot 
less expensive at this provider. The Plan denied your request. The Plan says the dental services were received 
from an out-of-network provider and are not covered by your supplemental benefits.  
 
Medicare generally does not cover dental services or services furnished outside of the United States. However, 
the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules 
apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for dental services provided in the Republic of North Macedonia on October 4, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that records have been submitted to show medical 
necessity. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the member is only noted to have 
"memory problems". The records did not support a diagnosis of either AD or FTD, let alone both conditions. In 
particular no symptoms of FTD were documented. This service would not meet criteria for coverage. 
 
 
  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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.