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

 
We decided that the Plan does not have to pre-approve endovenous ablation therapy of perforator veins. 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records show that this request is for calf perforator veins, and not a tributary of the 
saphenous vein. 
 
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 therapy. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the documentation does not meet coverage criteria and does not support the medical necessity of the 
procedures in question. Coverage criteria require that the veins to be treated are saphenous veins or their 
tributaries. As perforator veins are not tributaries of the saphenous veins, this criterion is not met. Additionally, 
criteria require that the enrollee have symptoms attributable to the veins in question that are impairing 
mobility. This criterion has also not been met.  
 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 therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve endovenous ablation therapy of perforator veins.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99100 and 99140 billed for date of service 
November 26, 2022. 
 
You asked the Plan to pay for procedure codes 99100 and 99140. You say that medical records were provided. 
The Plan denied your request. The Plan says procedure codes 99100 and 99140 are considered bundled and not 
separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure codes 99100 and 99140 have a status indicator of B on the Physician Fee Schedule. 
This means that procedure codes 99100 and 99140 are not separately payable. Based on this information, we 
decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure codes 99100 and 99140 billed for date of service November 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing amounts for the medical services provided on 
October 4, 2022, January 9, 2023, January 23, 2023, and January 31, 2023. 
 
You asked the Plan to waive the cost sharing amounts for the medical services provided on October 4, 2022, 
January 9, 2023 (EJFC3MZF2), January 23, 2023, and January 31, 2023. You say that you were not aware you 
would be charged for the storage of platelets and blood. You say that you have not been billed for all of your 
transfusions. You also say that these bills are very stressful for you. 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 $20 
copayment for Physician services.  
 
You have been asked to pay a $20 copayment for the medical services on October 4, 2022, and January 31, 
2023. These services fall within the primary care physician services benefit category. The $226 annual 
deductible was applied to the services received on January 9, 2023 (EJFC3MZF2), and January 23, 2023, in 
addition to the applicable copayments. 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 pay an additional amount for the 
medical services provided on October 4, 2022, January 9, 2023, January 23, 2023, and January 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, and 87653 billed for date of 
service October 15, 2022. 
 
You asked the Plan to pay for procedure codes 87150, 87481, and 87653. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says payment for codes 87150, 87481, and 87653 is 
bundled into payment for other codes. 
 
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 87150 
is a column II code to column I code 87500. We have confirmed that code 87481 is a column II code to column 
I code 87150. We have confirmed that code 87653 is a column II code to column I codes 87801 and 87150. 
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 codes 87150, 87481, and 87653 billed for date of service October 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for astigmatism-correcting intraocular lenses. 
 
You asked the Plan to pay for astigmatism-correcting intraocular lenses. You say that you would like to 
improve your vision. The Plan denied your request. The Plan says this is not a covered benefit. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of astigmatism-correcting intraocular lenses have not been met. Therefore, we decided that the Plan 
does not have to pay for astigmatism-correcting intraocular lenses.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an attendant control (E2331), mount (K0108), bracket 
switchbox (K0108), and side support armrest, inner/outer (K0108), and elbow stop (K0108). 
 
You asked the Plan to pre-approve the attendant control and associated hardware. You say that these items 
were not on the enrollee's current chair. You also say that this is a repair. The Plan denied your request. The 
Plan says attendant control cannot be covered for wheelchairs that already have a user-operated control. The 
Plan also says that armrests are already included with the approved power tilt and recline. 
 
The Plan follows Medicare rules. Medicare rules say that if an attendant control (E2331) is provided in addition 
to a beneficiary-operated drive control system, it will be denied as non-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 attendant control and associated 
hardware. Our reviewer says that the requested attendant control and associated hardware are not medically 
necessary. Our physician reviewer found the provided documentation indicates that the wheelchair has a 
beneficiary-operated drive control system. Therefore, the attendant control and associated hardware is 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 attendant control and associated hardware have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an attendant control (E2331), mount (K0108), bracket 
switchbox (K0108), and side support armrest, inner/outer (K0108), and elbow stop (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diabetic footwear and inserts. 
 
You asked the Plan to pre-approve foot orthotics. You say that you would like reconsideration because the 
requested diabetic footwear and inserts are medically necessary. The Plan denied your request. The Plan says 
this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve diabetic 
footwear and inserts.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and one power seating system motor (E2310). 
 
You asked the Plan to pre-approve an electronic connection between wheelchair controller and one power 
seating system motor. You say that the wheelchair evaluation clearly confirms and details that the enrollee 
meets the requested criteria. The Plan denied your request. The Plan says there is not a medical need to control 
the power option through the joystick. 
 
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 an electronic connection between 
wheelchair controller and one power seating system motor. Our reviewer says that the requested items/services 
are not considered medically reasonable and necessary in this case. Our physician reviewer found the provided 
records document that the enrollee has 3 out of 5 right upper extremity strength with functional hand and wrist 
range of motion, no contractures, and no reported limitations in self-feeding. Our reviewer also found that the 
records are inadequate to show the enrollee has inadequate upper extremity strength and function to operate the 
wheelchair's power options with their own switches.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electronic connection between wheelchair controller and one power seating 
system motor have not been met. Therefore, we decided that the Plan does not have to pre-approve an 
electronic connection between wheelchair controller and one power seating system motor (E2310).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for massage therapy visits provided from January 3, 2023, to 
February 23, 2023. 
 
You asked the Plan to pay for massage therapy visits. You say that the services were for physical therapy, not 
massage therapy and the provider does not accept insurance. The Plan denied your request. The Plan says 
massage therapists are not covered by Medicare or your health Plan. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pay for massage therapy visits provided from January 3, 2023, to 
February 23, 2023.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit for the evaluation and management provided on 
February 14, 2023. 
 
You asked the Plan to pay for a home visit for the evaluation and management. You say that the 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 a home visit for the 
evaluation and management provided on February 14, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious agent drug susceptibility phenotype provided on 
September 01, 2022. 
 
You asked the Plan to pay for infectious agent drug susceptibility phenotype. 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 infectious agent drug 
susceptibility phenotype provided on September 01, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a rest home visit provided on December 05, 2022. 
 
You asked the Plan to pay for a rest home visit. 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 a rest home visit 
provided on December 05, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. The Plan denied your request. The Plan says the service 
requested is not supported based on the records received. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does] not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for myocardial perfusion imaging provided on February 06, 
2023. 
 
You asked the Plan to pay for myocardial perfusion imaging. You say that the enrollee recently moved and was 
seen to reestablish care. 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 myocardial perfusion 
imaging provided on February 06, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on January 17, 2023. 
 
You asked the Plan to pay for a home visit. You say that the provider was not responsible for obtaining 
authorization. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a home visit provided on 
January 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to increase the reimbursement for the acupuncture services provided 
from July 2, 2022, to August 13, 2022. 
 
You asked the Plan to increase the reimbursement for the acupuncture services. You say that you were not 
reimbursed the correct amount and are owed $8.08. The Plan denied your request. The Plan says you were 
reimbursed the correct amount. 
 
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 35% 
coinsurance for out-of-network acupuncture services.  
 
 
 Date of Service CPT Allowed Amount Coinsurance Reimbursement 
July 2, 2022 97813 $46.89 $16.41 $30.48 
July 2, 2022 97814 $25 $8.75 $16.25 
July 16, 2022 97813 $46.89 $16.41 $30.48 
July 16, 2022 97814 $25 $8.75 $16.25 
July 30, 2022 97813 $46.89 $16.41 $30.48 
July 30, 2022 97814 $25 $8.75 $16.25 
August 13, 2022 97813 $46.89 $16.41 $30.48 
August 13, 2022 97814 $25 $8.75 $16.25 
Total $186.92 
 
Your reimbursement is based on the allowed amount for each service, not the billed amount. You have been 
reimbursed the allowed amount minus the 35% coinsurance for each acupuncture service. This item/service 
falls within the acupuncture for chronic low back pain benefit category. This means that you have been 
reimbursed 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 increase the reimbursement for the acupuncture services provided from July 2, 2022, to August 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the drug injection provided on December 
14, 2022. 
 
You asked the Plan to waive the coinsurance for the drug injection. You say that this is a cancer prevention and 
should not have a cost share amount. 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 20% 
coinsurance for Medicare Part B drugs. 
 
You have been asked to pay 20% coinsurance for the drug injection. This item/service falls within the 
Medicare Part B drugs 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 $78.69 ($393.46 allowed amount x 20% coinsurance = $78.69). 
Therefore, we decided that the Plan does not have to waive the coinsurance for the drug injection provided on 
December 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network primary care visit provided 
on October 26, 2022. 
 
You asked the Plan to waive the copayment for an in-network primary care visit. You say that you are 
dissatisfied with this provider, they do not listen to you. 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 $25 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $25 copayment for an in-network primary care visit. This item/service falls 
within the physician/practitioner services, including doctors office visits 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 an in-network primary care visit provided on October 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CGM. 
 
You asked the Plan to pre-approve a CGM. You say that you are requesting reconsideration of the denied 
authorization. The Plan denied your request. The Plan says that there is no evidence your current CGM has 
been lost or damaged. 
 
The Plan must follow Medicare rules. Medicare rules say that beneficiary owned items or a capped rental item 
may be replaced in cases of loss or irreparable damage. 
 
We looked at the file and Medicare rules. The record does not show any documentation that your current 
glucose monitor has been lost or damaged. Therefore, we decided that the Plan does not have to pre-approve a 
CGM.