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

 
We decided that the Plan does not have to pre-approve the non-pneumatic compression device to be provided 
by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the non-pneumatic compression device. You say that this service is not 
available from other providers. The Plan denied your request. The Plan says the enrollee must receive their care 
from a network provider (for more information about this, see Section 2 of Chapter 3). In most cases, care the 
enrollee receives from an out-of-network provider (a provider who is not part of the plans network) will not be 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the non-pneumatic compression device to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat (E0244). 
 
You asked the Plan to pre-approve a raised toilet seat. You say that the requested item is a necessity for your 
care. The Plan denied your request. The Plan says the requested 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.  
 
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 pre-approve a raised toilet seat (E0244).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for dermatology surgical services provided 
from June 20, 2023, through July 24, 2023. 
 
You asked the Plan to reduce the coinsurance for the dermatology surgical services. You say that this provider 
is in-network with the plan and the claims should be reprocessed. 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 45% 
coinsurance for out-of-network physician surgical services.   
 
You have been asked to pay 45% coinsurance of the allowed amount for the dermatology services. These 
services fall within the physician/practitioner 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 reduce the 
coinsurance for the dermatology surgical services provided on June 20, 2023, and July 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic services. 
 
You asked the Plan to pre-approve chiropractic services. You say that you are requesting reconsideration for 
the denied claim. The Plan denied your request. The Plan says they cover only manual manipulation of the 
spine to correct subluxation. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pre-approve chiropractic services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two air purifiers. 
 
You asked the Plan to pre-approve these services. You say that you know they aren't a covered item but they 
will be helpful to you. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve two air purifiers.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an adjustable bed (E1399) to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve an adjustable bed. You say that you have tried 8 companies through 
Medicare, but they did not have a queen size bed available. The Plan denied your request. The Plan says 
enrollees must receive their medical services from an in-network provider with the exception being urgent or 
emergent services. Non-emergent services with non-contracted providers require prior authorization before 
services being rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers.  
The requested provider in this case is not a network provider with the Plan and does not accept insurance. The 
Plan has network providers available who can provide the items/services at issue in this appeal. We found no 
exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan 
does not have to pre-approve an adjustable bed (E1399) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home visit for the evaluation and management of a new 
patient to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve home visit. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says this provider is 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
home visit for the evaluation and management of a new patient to be provided by an out-of-network (OON) 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block (64454). 
 
You asked the Plan to pre-approve a genicular nerve block. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 a genicular nerve block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the services are experimental for knee pain. 
 
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 genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block (64454).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99223) provided on May 8, 2023. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the service at issue was not billed with the required modifier to allow 
separate payment within the global surgery period. 
 
The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 49320 
provided on May 8, 2023. We find that the service at issue may be unrelated to the surgical procedure; 
however, the required modifier to indicate this was not used. As such, the billing rules for these services have 
not been met. Therefore, we decided that the Plan does not have to pay for physician services (99223) provided 
on May 8, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit (99285) provided May 22, 
2023. 
 You asked the Plan to pay for the emergency department visit. You say that the claim should be paid. The Plan 
denied your request. The Plan says the service is not supported by the records. 
 
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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 
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 emergency department visit. Our reviewer found the 
history/examination are medically appropriate; however, the documentation does not support high level 
decision-making. 
 
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 emergency department visit have not been met. Therefore, we decided that 
the Plan does not have to pay for the emergency department visit (99285) provided May 22, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested Intracept intraosseous 
basivertebral nerve ablation at L4 and L5, in this case, 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 an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on August 21, 
2023. 
 
You asked the Plan to waive the copayment for an office visit. You say that this service should be fully covered 
under the annual wellness visit. 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 $10 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $10 copayment for an office 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 office visit provided on August 21, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency care services (99285-CS and 93010) provided 
April 12, 2023. 
 
You asked the Plan to pay for the emergency care services. You say that the claim should be paid. The Plan 
denied your request. The Plan says the diagnosis codes should not be reported together which is based on the 
Excludes1 Notes instructions in the ICD-10-CM Official Guidelines for Coding and Reporting. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the emergency care services have not been met. The billed services 
99285-CS and 93010 were denied because the diagnosis codes associated to R44.0 (Auditory hallucinations) 
and F23 (Brief psychotic disorder), should not be reported together. The billed service has been denied because 
it was reported with one or more diagnosis code pairs that are subject to an Excludes1 note. Therefore, we 
decided that the Plan does not have to pay for the emergency care services (99285-CS and 93010) provided 
April 12, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit (99285) provided April 28, 
2023. 
 You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not supported by the records. 
 
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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 
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 service. Our reviewer found the documentation does not 
support a high level of medical decision complexity. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for the emergency department visit (99285) provided April 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an orthopedic visit provided on July 14, 
2023. 
 
You asked the Plan to waive the coinsurance for an orthopedic visit. You say that you were told this provider 
was in-network, and should be charged as such. 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 45% 
coinsurance for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay 45% coinsurance for an orthopedic 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. The total you owe is $47.62 ($106.79 x 45% = 
$47.62). Therefore, we decided that the Plan does not have to waive the coinsurance for an orthopedic visit 
provided on July 14, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit (99285) provided May 4, 
2023. 
 You asked the Plan to pay for the emergency department visit. You say that the claim should be paid. The Plan 
denied your request. The Plan says the service is not supported by the records. 
 
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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 
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 emergency department visit. Our reviewer found the 
history/examination are medically appropriate, but the documentation does not support high level decision-
making. 
 
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 emergency department visit have not been met. Therefore, we decided that 
the Plan does not have to pay for the emergency department visit (99285) provided May 4, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on August 08, 2023. 
 
You asked the Plan to pay for wound care supplies. You say that these supplies are a separately billable 
expense that do not require 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 wound care supplies 
provided on August 08, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction, erupted tooth requiring removal of bone 
and/or sectioning of tooth (D7210), bone replacement graft for ridge preservation - per site (D7953), non-
intravenous conscious sedation (D9248), and collection and application of autologous blood concentrate 
product (D7921) provided on July 20, 2023. 
 
You asked the Plan to pay for the dental services represented by codes D7210, D7953, D9248 and D7921. You 
say that this was a simple tooth extraction and you were unaware that the policy had an option for increased 
coverage for an additional $24 per month. You also say that you would gladly pay the premium for the last 
year, or a reasonable part thereof, to have the coverage retroactively in place.  The Plan denied your request. The Plan says dental services not included in the EOC or in excess of the benefit 
limits will be considered non-covered. 
 
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 
extraction, erupted tooth requiring removal of bone and/or sectioning of tooth (D7210), bone replacement graft 
for ridge preservation - per site (D7953), non-intravenous conscious sedation (D9248), and collection and 
application of autologous blood concentrate product (D7921) provided on July 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram and the office visit provided on 
September 07, 2023. 
 
You asked the Plan to pay for the electrocardiogram and the office visit. You say that you are requesting 
reconsideration of the denied claim. 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 electrocardiogram 
and the office visit provided on September 07, 2023.