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

 
We decided that the Plan does not have to pay for pathology services provided on December 8, 2022, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for pathology services. You say that the services should be covered. The Plan denied 
your request. The Plan says this was not authorized. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. 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 pathology services provided on December 8, 2022, 
by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee surgery provided on June 28, 2022. 
 
You asked the Plan to pay for the knee surgery. You say that the services were medically necessary. The Plan 
denied your request. The Plan says assistant surgeon services are not covered in his case. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 27301. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the 
knee surgery have not been met.  Therefore, we decided that the Plan does not have to pay for the knee surgery 
provided on June 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve partial upper denture (D5213) and partial lower denture 
(D5214). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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 requested item or service was exhausted on date of service December 8, 2020. 
Therefore, we decided that the Plan does not have to pre-approve partial upper denture (D5213) and partial 
lower denture (D5214).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression devices (E0675, E0673). 
 
You asked the Plan to pay for the pneumatic compression devices. You say that the items are medically 
necessary, The Plan denied your request. The Plan says these devices are not covered for preventative services 
during or after surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for the pneumatic compression devices (E0675, E0673).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services. 
 
You asked the Plan to pre-approve the dental services. You say that you would like to request reconsideration 
of the denied authorization. The Plan denied your request. The Plan says the services are not covered 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 pre-approve the 
dental services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS procedure. 
 
You asked the Plan to pre-approve CardioMEMS. You say that the Plan should approve this in light of the 
enrollee's specific clinical need and the scientific evidence for this technology. The Plan denied your request. 
The Plan says this is considered experimental/investigational. 
 
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 CardioMEMS. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case.  Our physician 
reviewer found there remains a dearth of randomized, blinded clinical studies examining the long-term clinical 
outcomes to establish the value of CardioMEMS in patient management. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CardioMEMS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the CardioMEMS procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Contour Next test strips. 
 
You asked the Plan to pre-approve the blood glucose test strips. You say that you are appealing the denied test 
strips. The Plan denied your request. The Plan says the necessary information requested from the provider 
within the Medicare required time frame was never received. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
  We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the blood glucose test strips have been 
met. Specifically, there were multiple attempts made to provide medical records. Without medical records there 
is not enough information to support the necessity of the requested items. Therefore, we decided that the Plan 
does not have to pre-approve Contour Next test strips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for crown - porcelain fused to high noble metal (D2750). 
 
You asked the Plan to pay more for dental services. You say that the service should be covered because root 
canal and crowns are a covered benefit. The Plan denied your request. The Plan says they reprocessed the claim 
with crown - porcelain fused to predominantly base metal (D2751), which is the lease costly method. 
  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers dental 
services when the services are medically necessary and reasonable. This benefit includes crown - porcelain 
fused to high noble metal covered once within 84 months per tooth, when teeth cannot be restored with regular 
filings due to fracture or decay. You pay 50% coinsurance after $100 deductible for class 3 major services. 
 
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 dental services. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the requested crown was high noble metal 
fused to porcelain. The Plan provided payment at the lesser cost of a non-precious metal fused to porcelain 
crown. So long as the member is not allergic to the non-precious metal, there is no functional difference 
between the different metal crowns. As the non-precious metal crown is of lesser cost, the Plan criteria was not 
met for the code D2750. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage that covers the crown - porcelain fused 
to high noble metal (D2750), the Plan processes it as crown - porcelain fused to predominantly base metal 
(D2751), and you are responsible up to the contracted fee. You are responsible for the difference between the 
allowed amounts. You also have a $100 deductible and a 50% coinsurance. Therefore, we decided that the Plan 
does not have to pay more for crown - porcelain fused to high noble metal (D2750).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99308-25 billed for date of service August 
16, 2022. 
 
You asked the Plan to pay for the billed services. You say that the code was billed due to changes in treatment.  
The Plan denied your request. The Plan says the code 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 code. 
 
We find that CPT code 99308-25 is not supported. Specifically, the records do not show that the evaluation and 
management service was unrelated to the wound debridement provided. Based on this information, we decided 
that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99308-25 billed for date of service August 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets LTACH admission 
criteria, and their ongoing medical care warrants an LTACH level of care to achieve a safe and sustainable 
discharge.  The Plan denied your request. The Plan says the requested LTACH admission is not medically 
necessary.  
 
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 that all medically necessary care is being provided in the current acute care setting.  
 There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the Plan. The Plan has approved ongoing care in the current acute care setting. The 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the outpatient surgery (0275T). 
 
You asked the Plan to pre-approve the outpatient surgery. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the member is not part of a clinical study. 
 
The Plan must follow Medicare rules. Medicare rules say that Percutaneous Image-Guided Lumbar 
Decompression (PILD) will be covered by Medicare when provided in a clinical study under section 
1862(a)(1)(E) of the Social Security Act (the Act) through Coverage with Evidence Development (CED) for 
beneficiaries with Lumbar Spinal Stenosis (LSS) who are enrolled in an approved clinical study. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the outpatient surgery have not been met. Therefore, we decided that the Plan does not have to pre-
approve the outpatient surgery (0275T).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for visits provided on January 24, 2023, to 
March 2, 2023. 
 
You asked the Plan to waive the copayments for visits. You say that you are disputing the share cost. 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 $35 
copayment for Outpatient mental health care.  
 
You have been asked to pay $35 copayment for each visit. This item/service falls within the Outpatient mental 
health care 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 copayments for visits provided on January 
24, 2023, to March 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for date of service September 
25, 2022. 
 
You asked the Plan to pay for the billed services. You say that the codes billed were justified. The Plan denied 
your request. The Plan says the billed code cannot be verified.  
 
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 care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and medical decision making of high complexity.  
 
We find that CPT code 99223 is not supported in the medical record. Specifically, the records do not include a 
comprehensive exam on the date of service at issue. Based on this information, we decided that Medicare rules 
for coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99223 billed for date of service September 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a raised toilet seat and sales tax. 
 
You asked the Plan to pay for a raised toilet seat and sales tax. You say that you bought a raised toilet seat 
because your toilets are older low models, and it was well worth the expense. You also say that yo would like 
to be reimbursed, as the seat was required to maintain your hip in place. The Plan denied your request. The 
Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature. The rules also say that Medicare does not make separate 
payment for sales tax. 
 
While a raised toilet seat may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pay for a raised toilet seat and sales tax.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for physician specialist services provided on 
March 14, 2022, to August 22, 2022. 
 
You asked the Plan to waive the copayments for physician specialist service. You say that you are disputing the 
share cost. 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 $35 
copayment for Physician/Practitioner services, including doctors 
office visits.  
 
You have been asked to pay $35 copayment for each physician specialist service. 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 copayments for physician specialist services provided on March 14, 2022, to August 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5298) purchased on September 15, 2021, 
from an out-of-network (OON) provider. 
 
You asked the Plan to pay for the hearing aids. You say that you got your hearing aids with an OON provider, 
but the claim was denied because the vendor is not part of the network. You also say that your plan has 
coverage for OON services. The Plan denied your request. The Plan says you chose to go to an OON provider 
without approval from the Plan. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when you use the Plan's approved hearing network vendor. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for 
the hearing aids (V5298) purchased on September 15, 2021, from an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on November 30, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the 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 the dental 
services on November 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 6 resin-based composites provided on November 30, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would not of had these procedures if they 
were not covered. The Plan denied your request. The Plan says your benefit for the requested item or service 
has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 requested item or service was exhausted on date of service November 30, 2022. 
Therefore, we decided that the Plan does not have to pay for 6 resin-based composites provided on November 
30, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the ambulance transportation and the 
emergency room visit provided on December 13, 2022. 
 
You asked the Plan to waive the copayments for the ambulance transportation and the emergency room visit. 
You say that you should not have to pay an emergency room copayment due to being admitted to a different 
hospital. 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 $225 
copayment for each in-network Medicare-covered one-way ambulance trip. Your contract with the Plan also 
clearly says that you must pay a $90 copayment Medicare-covered emergency room visits. 
 
You have been asked to pay a $225 copayment for the ambulance transportation. This item/service falls within 
the ambulance services benefit category. You have also been asked to pay a $90 copayment for the emergency 
room visit. This item/service falls within the emergency care benefit category. You have been asked to pay a 
total of $315 ($225 copayment + $90 copayment + $315). 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 copayments 
for the ambulance transportation and the emergency room visit provided on December 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bifocal lens and the frames provided on December 30, 
2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the bifocal lens and the frame. You say that you are appealing the denial of this 
claim. The Plan denied your request. The Plan says the provider was out-of-network and authorization was not 
obtained. 
 
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 
bifocal lens and the frames. We found no exception that would require the Plan to pay for the bifocal lens and 
the frames. Therefore, we decided that the Plan does not have to pay for the bifocal lens and the frames 
provided on December 30, 2022, by an out-of-network (OON) provider.