Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the wheelchair (K0001) and sales tax 
(S9999) 
 
You asked the Plan to waive the copayment for the wheelchair and sales tax. You say that the item should be 
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 20% 
coinsurance for Durable medical equipment (DME) and related supplies. Medicare does not reimburse separately for sales tax.  
 
You have been asked to pay 20% coinsurance for the wheelchair and sales tax. This item/service falls within 
the Durable medical equipment (DME) and related supplies 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 wheelchair (K0001) and sales tax (S9999)
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomographic angiography (CTA) of the 
heart. 
 
You asked the Plan to pre-approve the CTA. You say that the records provided support medical necessity. The 
Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that the enrollee must meet at least one indication as listed 
in the LCD in the Medicare rules section. 
 
 
  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 CTA. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found radionuclide stress test performed in 2019 
was normal and echocardiography in 2022 showed normal left ventricular function. The patient continues to 
deny any cardiac symptoms and physical exam is negative. Clinical guidelines for the use of CTA have not 
been met based on review of the submitted clinical documentation. 
 
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 CTA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a computed tomographic angiography (CTA) of the heart.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of a lower extremity. 
 
You asked the Plan to pre-approve the CT scan. You say that the records provided support medical necessity. 
The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 CT scan. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found a CT scan is not needed for a patient with 
knee degenerative joint disease who is having total knee surgery. Mako robotic surgery has not been shown to 
have better functional outcomes than conventional open surgery without robotic assistance. 
 
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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) scan of a lower extremity.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from 
August 5, 2023, to September 3, 2023. 
 
You asked the Plan to pay for the SNF services. You say that you are requesting reconsideration for the denied 
services. The Plan denied your request. The Plan says the Plan has already covered 100 days of SNF care. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from February 5, 
2023, to August 4, 2023. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from August 5, 2023, 
to September 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation services. 
 
You asked the Plan to pre-approve the additional routine transportation. You say that the services are necessary 
to make it to your appointments. The Plan denied your request. The Plan says the routine transportation benefit 
has been exhausted. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way non-emergency ground transportation trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of a lower extremity. 
 
You asked the Plan to pre-approve the CT scan. You say that the scan is needed to evaluate bony limb 
alignment with femoral patellar and tibial relationship for appropriate implant placement. The Plan denied your 
request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 CT scan. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found a CT scan is not needed for a patient with 
knee degenerative joint disease who is having total knee surgery. Mako robotic surgery has not been shown to 
have better functional outcomes than conventional open surgery without robotic assistance. 
 
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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) scan of a lower extremity.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pickleball instruction class provided on June 20, 2023. 
 
You asked the Plan to pay for pickleball instruction class. You say that you were a few days late submitting 
your reimbursement form due to cancer. The Plan denied your request. The Plan says the class is not 
considered a qualified health club or fitness facility. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
only membership in a qualified health club or fitness facility. 
 
 
 The Plans rules for coverage of gym benefits have not been met. Specifically, pickleball is considered a sport, 
and is not a covered benefit. Therefore, we decided that the Plan does not have to pay for the pickleball 
instruction class provided on June 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the office visit (99214) provided on 
August 9, 2023. 
 
You asked the Plan to waive the coinsurance for the office visit. You say that the service should be 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. Your 
contract with the Plan says that there is a $800 deductible which applies to doctor and other health care 
provider services. There is also a 10% coinsurance for doctor and other health care provider services. 
Coinsurance is applied before and in addition to the deductible amount. 
 
The item or service you asked the Plan to waive the coinsurance for falls within the doctor and other health 
care provider services benefit category. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is a $800 deductible which applies to doctor and other health care provider services. This 
cost sharing is a contractual obligation that had not been met at the time the office visit was received on August 9, 2023. Therefore, we decided that the Plan does not have to waive the coinsurance for the office visit (99214) 
provided on August 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 40 additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional trips. You say that you need the additional transportation for 
your medical consultations. You also say that you are doing a TMS treatment that was approved, and as per 
FDA and insurance, the treatment has to be done every day, for 35 days. The Plan denied your request. The 
Plan says you have exhausted your routine transportation benefits for 2023. Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 72 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve the 
additional trips for your consultations and TMS treatments. Based on this information, we decided that you 
have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that 
the Plan does not have to pre-approve 40 additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and an intraoral first x-ray 
(D0220) provided on September 14, 2023. 
 
You asked the Plan to pay for a limited oral evaluation (D0140) and an intraoral first x-ray (D0220) . You say 
that your insurance covers a basic oral evaluation and x-ray. You also say you are having sensitivity to cold and 
your gums above your teeth are red and a little swollen. The Plan denied your request. The Plan says these 
services are 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 limited 
oral evaluation (D0140) and an intraoral first x-ray (D0220) provided on September 14, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81455 billed for date of service June 12, 
2023. 
 
You asked the Plan to pay for the billed testing. You say that the test assists in treatment of the enrollee. The 
Plan denied your request. The Plan says the test is not covered. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and the rules. In this case, there are insufficient medical records that document the 
enrollees stage of cancer. The records are not sufficient enough to determine if the testing met the coverage 
criteria.  Based on this information, we decided that Medicare rules for coverage of the billed testing have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure code 81455 billed for date of 
service June 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management services described by code 
99221 billed for date of service June 29, 2023. 
 
You asked the Plan to pay for 99221. You say that 99221 should be covered because the enrollee was seen for 
the first time by this provider and the decision for surgery was made. The Plan denied your request. The Plan 
says 99221 is not supported in the documentation and is included in the global surgery period of the surgical 
procedure billed on the same date by the same provider. 
 The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. In this case, we confirmed that the provided medical records do not 
include an evaluation and management note for the billed date of service, June 29, 2023. While the record 
contains a surgical procedure note for this date of service and an evaluation and management note dated March 
4, 2023, there is no documentation in the medical records of an evaluation and management service performed 
on June 29, 2023. Based on this information, we decided that there is insufficient information in the record to 
determine if Medicare rules for coverage of 99221 have been met. Therefore, we decided that the Plan does not 
have to pay for the evaluation and management services described by code 99221 billed for date of service 
June 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve partial lower denture (D5212). 
 
You asked the Plan to pre-approve partial lower denture (D5212). You say that you are on a fixed income, and 
cannot afford the partial dentures. You also say you have lost your bottom partial and eating is difficult. 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 
partial lower denture (D5212).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve maxillary partial denture (D5213). 
 
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 February 10, 2021. 
Therefore, we decided that the Plan does not have to pre-approve maxillary partial denture (D5213).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on August 2, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were told that you had not used all of your 
benefits for the past couple of years, so this should be covered. The Plan denied your request. The Plan says 
your annual dental allowance amount 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 annual dental allowance amount was exhausted on date of service July 18, 2023. Therefore, we 
decided that the Plan does not have to pay for dental services provided on August 2, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the multifocal intraocular lens. 
 
You asked the Plan to pre-approve the multifocal intraocular lens. You say that you have Parkinson's disease 
and had an implantation in your brain which has affected your vision. The Plan denied your request. The Plan 
says the service is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives a P-C IOL 
during cataract surgery, the enrollee will be responsible for the difference in cost between the P-C IOL and a 
conventional IOL.  
 
While a P-C IOL may be appropriate for you, neither the Plan nor Medicare covers the presbyopia-correcting 
feature of a P-C IOL. Therefore, we decided that the Plan does not have to pre-approve the multifocal 
intraocular lens.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve partial upper denture (D5211), and partial lower denture 
(D5212). 
 
You asked the Plan to pre-approve partial upper and lower denture. 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 
partial upper denture (D5211), and partial lower denture (D5212).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 25, 2023, to 
August 22, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that you provided proof that you 
timely filed your claim. The Plan denied your request. The Plan says the claim has not been billed with the 
correct admission date. The NOA and the claim have different admission dates. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from July 25, 2023, to August 
22, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opzelura cream. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee's condition has improved with this 
medication. 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 Opzelura cream.  
 
Benefits for the medication 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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab testing billed for date of service March 24, 2023. 
 
You asked the Plan to pay for the billed testing. You say that the test results lead to significant improved 
outcomes. The Plan denied your request. The Plan says that the test is not a covered service. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
We looked at the file and the rules. The MolDX program requires tests to be reviewed to determine whether 
Medicare reasonable and necessary requirements are met. In this case, the provided PrismRA test is a covered 
test under the MolDX program. The Plan has not made reasonable and diligent efforts to gather and forward to 
us information regarding their decision to deny your request. Therefore, we decided that the Plan has to pay for 
the lab testing billed for date of service March 24, 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.