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

 
We decided that the Plan does not have to pay for medical nutrition therapy provided on August 16, 2023. 
 
You asked the Plan to pay for medical nutrition therapy services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says medical nutrition therapy is only a covered benefit for 
enrollees who have diabetes or a renal disease. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the 
Plan does not have to pay for medical nutrition therapy provided on August 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diabetic supplies provided on June 30, 2023. 
 
You asked the Plan to pay for diabetic supplies. You say that you have provided all of the appropriate 
information. The Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery. The proof of delivery provided does not have the 
enrollees signature. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for diabetic supplies 
provided on June 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a positive airway pressure device filter (A7038) provided on 
September 12, 2023. 
 
You asked the Plan to pay for the positive airway pressure device filter. You say that this equipment was 
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that two (2) accessories every month represents the 
usual maximum amount for this type of accessory expected to be medically necessary. 
 
We looked at the file and Medicare rules. Between July and August 2023, 6 filters were provided. The 
additional 2 filters provided exceed the allowed amount. Based on this information, we decided that Medicare 
rules for coverage of the positive airway pressure device filter have not been met. Therefore, we decided that 
the Plan does not have to pay for a positive airway pressure device filter (A7038) provided on September 12, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on July 26, 2023, billed with 
procedure code 99223. 
 You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the diagnosis code at issue is not appropriate as a 
primary diagnosis. 
 
The Plan must follow Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. These guidelines state that certain codes are manifestation codes, denoted with a code first note, or 
in diseases classified elsewhere in the code definition. Another diagnosis code should be sequenced before a 
manifestation code if applicable.  
 
We looked at the file and Medicare rules. This claim was billed with primary diagnosis code F09, described as 
unspecified mental disorder due to known physiological condition. This code is not an appropriate primary 
diagnosis as the code has a code first note indicating to code the underlying condition first. Based on this 
information, we decided that Medicare rules for payment of this claim have not been met. Therefore, we 
decided that the Plan does not have to pay for practitioner services provided on July 26, 2023, billed with 
procedure code 99223.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345 billed for date of service July 17, 
2023. 
 
You asked the Plan to pay for procedure code 81345. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says payment for code 81345 is bundled into payment for code 0089U. 
 
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 code 81345 
is a column II code to column I code 0089U. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 code 81345 billed for date of service July 17, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the Intracept procedure is medically 
necessary. The Plan denied your request. The Plan says the Intracept procedure is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Intracept procedure. Our reviewer 
says that the requested Intracept procedure is not considered medically reasonable and necessary. Our 
physician reviewer found there is no magnetic resonance imaging (MRI) showing only Modic changes without 
facet degenerative joint disease or stenosis. The cause of pain is not clear. 
  
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an OON provider on August 16, 
2023. 
 
You asked the Plan to pay for the dental services. You say that this was medically necessary. 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. 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 by an OON provider on August 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the complete upper denture (D5110) and the 
complete lower denture (D5120) provided on June 16, 2023. 
 
You asked the Plan to issue reimbursement for the dental items. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the dental items 
in this case are not payable as they were rendered by a provider who is not enrolled in the Medicare program.   
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
A review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to issue reimbursement for the complete upper 
denture (D5110) and the complete lower denture (D5120) provided on June 16, 2023.
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 
August 24, 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 an 
incisional biopsy of oral tissue-soft (D7286) provided on August 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nerve treatment on front tooth for tooth 27 (D3310). 
 
You asked the Plan to pre-approve nerve treatment. You say that this should be covered. The Plan denied your 
request. The Plan says this is not a covered service. 
 
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 pre-approve 
nerve treatment on front tooth for tooth 27 (D3310).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuous glucose monitor (CGM) (A4239, E2103) 
provided on June 27, 2023. 
 
You asked the Plan to pay for the CGM. You say that the items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the items denied correctly as the rendering provider is not 
enrolled with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for continuous glucose monitor (CGM) 
(A4239, E2103) provided on June 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits (99211) provided from June 19, 2023, to 
August 14, 2023. 
  
You asked the Plan to pay for the office visits. You say that the services should be covered with a $30 
copayment. The Plan denied your request. The Plan says the services are not covered benefits. 
 
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 services at issue are not manual manipulations of the spine. Therefore, we decided 
that the Plan does not have to pay for the office visits (99211) provided from June 19, 2023, to August 14, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2751) for tooth #29 provided on September 25, 
2023. 
 
You asked the Plan to pay for a crown. You say that you needed this dental work. The Plan denied your 
request. The Plan says the rendered dental service is not a covered benefit. 
 
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 crown 
(D2751) for tooth #29 provided on September 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dermatology visit provided on July 25, 2023. 
 
You asked the Plan to pay for a dermatology visit. You say that you feel you were misled by the office. They 
told you that the provider would be in-network, and you are now getting a bill for the full amount of the 
appointment. 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 $950 out-of-network deductible which applies to 
physician/practitioner services, including doctors office visits. Youve been asked to pay $121.21 towards this 
deductible. 
 
The item or service you asked the Plan to pay 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 $950 out-of-network 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 a dermatology visit was received 
on July 25, 2023. Therefore, we decided that the Plan does not have to pay for a dermatology visit provided on 
July 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral-periapical additional radiographic images 
(D0230 x 4), panoramic radiographic image (D0330), adjunctive pre-diagnostic test that aids in the detection of 
mucosal abnormalities (D0431), and the comprehensive oral evaluation (D0150) provided on July 31, 2023. 
 
You asked the Plan to pay 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 your benefit for the intraoral x-rays, 
panoramic radiographic image, and the comprehensive oral evaluation provided has already been exhausted. 
Additionally, the adjunctive pre-diagnostic test provided is not a covered benefit.  
  
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 intraoral x-rays, panoramic radiographic image, and the comprehensive oral 
evaluation provided has already been previously exhausted. Specifically, the Plans contract states that one 
intraoral x-ray is covered per calendar year. On this day, you received five intraoral x-rays, in which one x-ray 
was paid for by the Plan. Therefore, you have exhausted the allowable benefit for this service. The Plans 
contract states that one comprehensive oral evaluation is covered every three calendar years. You previously 
received this service on March 25, 2022, less than three years prior, which was paid for by the Plan. Therefore, 
you have exhausted the allowable benefit for this service. The Plans contract also states that one full mouth  
x-ray or panoramic radiographic image is covered every five calendar years. You previously received a full 
mouth x-ray on March 25, 2022, less than five years prior, which was paid for by the Plan. Therefore, you have 
exhausted the allowable benefit for this service. Additionally, an adjunctive pre-diagnostic test is not a covered 
benefit under the supplemental dental policy. Therefore, we decided that the Plan does not have to pay for the 
intraoral-periapical additional radiographic images (D0230 x 4), panoramic radiographic image (D0330), 
adjunctive pre-diagnostic test that aids in the detection of mucosal abnormalities (D0431), and the 
comprehensive oral evaluation (D0150) provided on July 31, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diabetic shoes to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve diabetic shoes. You say that the in-network providers are out of state and 
too far away. This patient cannot go that far. The Plan denied your request. The Plan says there are other 
providers available who are in-network, who are within the Medicare allowable distance from the beneficiary's 
residence.  
 
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 
diabetic shoes to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing (87641, 87653, 87640, 87481, 87798) provided on 
April 13, 2023. 
 
You asked the Plan to pay for the lab testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.   
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for lab testing (87641, 87653, 87640, 87481, 87798) provided on April 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Pilates machine (A9300). 
 
You asked the Plan to pre-approve the Pilates machine. You say that this machine is medically necessary. The 
Plan denied your request. The Plan says exercise equipment is not a covered service. 
 
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 Pilates machine (A9300).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve rock steady boxing classes. 
 
You asked the Plan to pre-approve rock steady boxing classes. You say that you need rock steady boxing 
classes to help you with your condition of Parkinson Disease. You say rock steady boxing is a nationally 
recognized program for people with Parkinson Disease. The Plan denied your request. The Plan says 
supervised exercise therapy is only covered when you have a diagnosis of peripheral artery disease (PAD). 
 
The Plan contract says that Supervised Exercise Therapy (SET) is covered for members who have 
symptomatic peripheral artery disease (PAD) and a referral for PAD from the physician responsible for PAD 
treatment. 
 
We looked at the file and the Plans rules. The file shows that supervised exercise therapy is only covered when 
you have a diagnosis of peripheral artery disease. Therefore, we decided that the Plan does not have to pre-
approve supervised exercise therapy (rock steady boxing classes).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy duty bariatric hospital bed (E0303). 
 
You asked the Plan to pre-approve the heavy duty bariatric hospital bed. You say that this item is medically 
necessary. The Plan denied your request. The Plan says rules for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a heavy duty extra wide hospital bed (E0301, 
E0303) is covered if the beneficiary meets one of the criteria for a fixed height hospital bed and the 
beneficiary's weight is more than 350 pounds, but does not exceed 600 pounds. The rules also say duplicate 
equipment is not covered. 
 
We looked at the file and Medicare rules. The records do not show that the enrollee's weight is in excess of 350 pounds. Additionally, the records show that the plan has already approved a standard size semi-electric hospital 
bed (E0260). Based on this information, we decided that Medicare rules for coverage of the heavy duty 
bariatric hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
heavy duty bariatric hospital bed (E0303).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation-diagnostic service provided by a dentist or 
physician other than requesting dentist or physician (D9310) on September 14, 2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service provided is not covered under the 
supplemental dental policy.  
 
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 service provided is not among 
those covered under this benefit.  
  
 
Therefore, we decided that the Plan does not have to pay for the consultation-diagnostic service provided by a 
dentist or physician other than requesting dentist or physician (D9310) on September 14, 2023.