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

 
We decided that the Plan does not have to waive the copayment for chiropractic services provided on June 29, 
2023. 
 
You asked the Plan to waive the copayment for chiropractic services. You say that you disagree with the 
copayment. 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 $15 
copayment for chiropractic services.  
 
You have been asked to pay a $15 copayment for chiropractic services. This item/service falls within the 
chiropractic services 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 chiropractic services 
provided on June 29, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided from June 27, 2023, to 
June 28, 2023. 
 
You asked the Plan to pay for the medications. You say that you cannot afford to pay these charges. The Plan 
denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided from June 27, 2023, to June 28, 2023.  
 
Benefits for the medications may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a group 1 standard power operated vehicle (K0800).  
 
You asked the Plan to pre-approve a group 1 standard power operated vehicle. You say that you need a power 
chair to get around. The Plan denied your request. The Plan says that based on Medicare guidelines, the 
requested power operated vehicle does not meet the requirements for approval. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will be covered if the patient has a mobility 
deficit that impairs their participation in MRADLs, the patients condition cannot be ameliorated by a walker, 
cane or manual wheelchair, and the patient is capable of safely operating the requested PMD.  
 
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 1 standard power operated 
vehicle. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found you 
have impaired mobility and cannot functionally ambulate with a cane or walker due to lower extremity 
weakness and shortness of breath due to COPD. You are unable to propel a manual wheelchair due to upper 
extremity weakness and shortness of breath due to COPD. Our reviewer found that the documentation indicates 
that you have the capability to operate the requested power scooter, both mentally and physically. Our 
physician reviewer also found that you require a power scooter for mobility and performing daily activities. 
 
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 1 standard power operated vehicle have been met. Therefore, we decided that the Plan has to pre-
approve a group 1 standard power operated vehicle (K0800).   
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Comprehensive PGX hereditary pharmacogenomic 
testing and the Comprehensive Cardio hereditary genetic testing provided on March 20, 2023. 
 
You asked the Plan to pay for the Comprehensive PGX hereditary pharmacogenomic testing and the 
Comprehensive Cardio hereditary genetic testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services are not payable as billed. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The Comprehensive PGX hereditary pharmacogenomic testing and the Comprehensive Cardio hereditary 
genetic testing at issue was requested solely for screening purposes. Medicare does not cover this test solely for 
screening purposes. Therefore, we decided that the Plan does not have to pay for the Comprehensive PGX 
hereditary pharmacogenomic testing and the Comprehensive Cardio hereditary genetic testing provided on 
March 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics.  
 
You asked the Plan to pre-approve foot orthotics. You say that the items 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 you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous revascularization of the lower extremity 
including stenting (37229, 37228, 37227, 37226, 37225, 37224, 37221, 37220). 
 
You asked the Plan to pre-approve percutaneous revascularization of the lower extremity including stenting. 
You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically 
necessary because the records do not show that the enrollee has any vascular blockages in the lower 
extremities. 
 
The Plan follows Medicare rules. Medicare rules say that PTA and stenting can be covered when specific 
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 percutaneous revascularization of the 
lower extremity including stenting. Our reviewer says that the requested service is not medically necessary. 
Our physician reviewer found there is no suggestion of limb threat. In its current form, the documentation does 
not support the likelihood that the enrollee will get meaningful improvement walking distance or quality of life 
from the procedures in question. The documentation does not include a complete lower extremity pulse 
examination and does not include non-invasive findings suggestive of significant lower extremity arterial 
occlusive disease. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous revascularization of the lower extremity including stenting have 
not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous revascularization 
of the lower extremity including stenting (37229, 37228, 37227, 37226, 37225, 37224, 37221, 37220).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99309 for date of service March 28, 2023. 
 
You asked the Plan to pay for procedure code 99309. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not supported. 
 
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 99309 is Subsequent nursing facility care, per day, for the 
evaluation and management of a patient, which requires a medically appropriate history and/or examination 
and moderate level of medical decision making. When using total time on the date of the encounter for code 
selection, 30 minutes must be met or exceeded. 
 
 
 We find that CPT code 99309 is not supported in the medical record. Specifically, the documentation submitted 
did not include medical records. Without medical records, this code for this date of service cannot be verified. 
Based on this information, we decided that Medicare rules for coverage of procedure code 99309 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 99309 for date of service 
March 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the new patient office visit, and the allergy 
immunotherapy services provided by an out-of-network provider from September 20, 2022, to July 6, 2023. 
 
You asked the Plan to waive the cost sharing for the office visit and the allergy immunotherapy services. You 
say that you were told that the provider was in-network. 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 $750 deductible which applies to all services besides covered services 
received from an in-network provider, ambulance services, emergency room services, and urgently needed 
services at urgent care centers. Your contract with the Plan also says that you must pay a 50% coinsurance of 
the total cost for out-of-network Medicare Part B chemo drugs, and other Medicare Part B drugs, and a $65 
copayment for out-of-network Medicare-covered physician specialist services. 
 
The items or services you asked the Plan to waive the cost sharing for were provided by an out-of-network 
provider. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 
deductible which applies to out-of-network services. This cost sharing is a contractual obligation that had not 
been met at the time the office visit and the allergy immunotherapy services were received on September 20, 
2022, to July 6, 2023. Therefore, we decided that the Plan does not have to waive the cost sharing for the new 
patient office visit, and the allergy immunotherapy services provided by an out-of-network provider from 
September 20, 2022, to July 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services (D5112). 
 
You asked the Plan to pre-approve dental services (D5112). You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says this 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 pre-approve 
dental services (D5112).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit and services provided on August 
31, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the outpatient office visit and services. You say that due to not knowing you 
needed a referral, there is an unpaid invoice due from last years visit and payment has been denied by the Plan. 
You also say that you are requesting help and payment to the provider for their continued services on your 
behalf. The Plan denied your request. The Plan says the treating provider is not a network provider with the 
Plan. The Plan also says that these services are not urgent or emergent, nor were they approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the outpatient office visit and services provided on 
August 31, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair repairs. 
 
You asked the Plan to pre-approve power wheelchair repairs. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the requested services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that says the repair costs must be less than the 
replacement cost. 
 
We looked at the file and Medicare rules. Review of the file shows that the requested repair costs are more than 
the replacement cost. Based on this information, we decided that Medicare rules for coverage of power 
wheelchair repairs have not been met. Therefore, we decided that the Plan does not have to pre-approve power 
wheelchair repairs.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ozempic (C9399). 
 
You asked the Plan to pre-approve the medication. You say that this is medically necessary for the enrollee's 
treatment for type 2 diabetes mellitus. The Plan denied your request. The Plan says the medication is not 
covered as a medical benefit under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ozempic (C9399).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on March 13, 2023. 
 
You asked the Plan to pay for the office visit. You say that the service 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 the office visit provided 
on March 13, 2023.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay $14 and waive the $31 difference between the billed and allowed amount 
for an amalgam filling. We decided that the Plan does not have to waive the $50 copayment, $50 deductible, or 
the $14 coinsurance for an amalgam filling.  
 
  You asked the Plan to pay for an amalgam filling. You say that this should be covered. The Plan says that you 
are responsible for the full billed amount. 
 
We decided that the Plan has to reduce your cost for the filling. We also decided the Plan must pay the 
remaining $14 and waive the $31 difference between the billed and allowed amount 
 
The Plan says you are responsible for the full billed amount. However, the Evidence of Coverage states you are 
only responsible for a $50 deductible, $50 office visit copayment and 50% coinsurance. In addition, this 
provider is a contract provider, and you cannot be held liable for the difference between the billed and allowed 
amount. Therefore, you are only responsible for $114 for the filling. The Plan must pay the remaining $14 and 
waive the $31 difference between the billed and allowed amount. 
 
Service Allowed Amount Deductible Copayment Coinsurance Your Total Cost 
Filling $128 $50 $50 $14 $114 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the telehealth evaluation provided on June 
26, 2023. 
 
You asked the Plan to waive the copayment for the telehealth evaluation. You say that this service should be 
fully covered. 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 $45 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $45 copayment for the telehealth evaluation. 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 the telehealth evaluation provided on June 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 20, 2022. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says this claim 
was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the laboratory services was not filed until February 2, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the laboratory services provided on January 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (procedure code 99233) rendered on 
May 17, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 99233 (1 unit) remains not supported. 
 
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 99233 is "Subsequent 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, 50 minutes must be met or exceeded." 
 We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the documentation supports an 
appropriate exam, but not an appropriate history or medical decision making of high level or that 50 minutes 
were spent. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for subsequent hospital care (procedure code 99233) rendered on May 17, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code Q0092 billed for date of service April 26, 2023. 
 
You asked the Plan to pay for the billed service. You say that you are entitled up to 4 units per x-ray. The Plan 
denied your request. The Plan says that records were not received to support the billed services. 
 
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 Q0092 is set-up portable x-ray equipment. We find that 3 
units of CPT code Q0092 is supported. The claim shows that 3 x-rays (72040, 72070, and 72100) were 
provided. Carriers must pay a set-up component for each radiologic procedure. The MUE for CPT code Q0092 
is 3. The MAI value for this code is 3. You billed 3 units of this code. Based on this information, we decided 
that Medicare rules for coverage of the billed service have been met. Therefore, we decided that the Plan has to 
pay for procedure code Q0092 billed for date of service April 26, 2023.  
 
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.