Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation (D9310), cone beam CT (D0364), 
apicoectomy (D3425. D3421) and retrograde filling - per root (D3430 x 2) provided on August 1, 2023, to 
August 10, 2023. 
 
You asked the Plan to pay for these dental services. 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 pay for a 
consultation (D9310), cone beam CT (D0364), apicoectomy (D3425. D3421) and retrograde filling - per root (D3430 x 2) provided on August 1, 2023, to August 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bike (A9300). 
 
You asked the Plan to pre-approve the bike. You say that the bike is medically necessary. The Plan denied your 
request. The Plan says this item is 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 a bike (A9300).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the Lasik eye surgery (S0800) provided on 
March 24, 2022. 
 
You asked the Plan to issue reimbursement for this service. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says this service is not payable as the 
claim was submitted untimely.  
 
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 this service was not filed until May 11, 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 issue reimbursement for the Lasik eye surgery (S0800) provided on March 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services provide don April 7, 2023, to May 
01, 2023. 
 You asked the Plan to pay for the acupuncture services. You say that the claim should be reprocessed for 
payment. The Plan denied your request. The Plan says acupuncture is only covered for chronic low back pain. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the enrollee has pain in their right shoulder, and 
acupuncture is only covered for chronic low back pain. Therefore, we decided that the Plan does not have to 
pay for the acupuncture services provide don April 7, 2023, to May 01, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the installation of a safety banister you purchased on July 2, 
2023. 
 
You asked the Plan to pay for the banister installation. You say that the installation of this banister should be 
covered. 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 grab bars are not covered because they are not primarily 
medical in nature. Your Plan does offer an additional benefit that covers grab bars.  However, your contract 
with the Plan explicitly states that this coverage excludes the cost of installation of these devices. Therefore, we 
decided that the Plan does not have to pay for the installation of a safety banister to go up the stairs (i.e., a type 
of grab bar) you purchased on July 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established 
patient (D0150) provided on October 17, 2023. 
 
You asked the Plan to pay for the dental service. You say that you decided to change dentists and had to go 
through the standard procedure of having x-rays taken. You also say that you called the plan however you were 
not told the x-rays would have been covered, and you assumed your balance for that year would have covered 
the procedure. The Plan denied your request. The Plan says your benefit for the requested 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 service was exhausted on dates of service February 23, 2023, and 
September 5, 2023. Therefore, we decided that the Plan does not have to pay for the comprehensive oral 
evaluation - new or established patient (D0150) provided on October 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service August 13, 
2023, to September 9, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that these services were medically necessary and 
arranged by a network provider. The Plan denied your request. The Plan says the billed code is invalid for 
Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service August 13, 2023, to September 9, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the monitoring device (A9279) provided on September 16, 
2023. 
 
You asked the Plan to pay for monitoring device. You say that the claim was denied for being untimely. The 
Plan denied your request. The Plan says that the item is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that claims for A9279 (Monitoring Feature/Device, 
Stand-Alone or Integrated, Any Type, Includes All Accessories, Components and Electronics, Not Otherwise 
Classified) are denied as statutorily non-covered (No Medicare Benefit). 
 
We looked at the file and Medicare rules. The monitoring device at issue is non-covered by Medicare. Based 
on this information, we decided that Medicare rules for coverage of monitoring device have not been met. 
Therefore, we decided that the Plan does not have to pay for the monitoring device (A9279) provided on 
September 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on 
August 21, 2023. 
 
You asked the Plan to pay for the dental service. You say that the provider was unaware that the Plan would 
only cover 1 x-ray every 5 years. 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 the Plan paid for an intraoral complete series of radiographic images (D0210) on August 21, 2023; 
therefore, your benefit for the requested item or service was exhausted on the date of service of August 21, 
2023. Therefore, we decided that the Plan does not have to pay for a panoramic radiographic image (D0330) 
provided on August 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341 billed for date of service May 31, 
2023.  
 
You asked the Plan to pay for procedure code 88341. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88341 is 13. The MAI value for this code is 3. You billed 21 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 88341 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88341 billed for date of service May 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206), scaling in 
presence of generalized moderate or severe gingival inflammation (D4346) and gingival irrigation with a 
medicinal agent (D4921 x 4) provided on September 14, 2023. 
 
You asked the Plan to pay for the dental services. You say that you cannot afford to pay for these procedures. 
You did not realize these procedures were not covered and your provider did not inform you. The Plan denied 
your request. The Plan says these services are not covered benefits under your dental plan. 
 
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 
topical application of fluoride varnish (D1206), scaling in presence of generalized moderate or severe gingival 
inflammation (D4346) and gingival irrigation with a medicinal agent (D4921 x 4) provided on September 14, 
2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the destruction of skin growth provided on March 27, 2023, 
by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the destruction of skin growth. You say that the procedure is medically necessary 
for the enrollee. The Plan denied your request. The Plan says the destruction of skin growth is available in 
network.  
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 the destruction of skin growth provided on March 
27, 2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics provided on August 3, 2023.  
 
You asked the Plan to pre-approve foot orthotics. You say that you would like reconsideration because the 
requested foot orthotics 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 provided on August 
3, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 73590 billed for date of service August 22, 2023. 
 
You asked the Plan to pay for code 73590. You say that this is a payable code. The Plan denied your request. 
The Plan says this code is not separately payable. 
 
The Plan must follow Medicare rules. The rules say that STV-packaged services are services for which separate 
payment is made only if there is no service with status indicator S, T, or V reported on the same claim. If a 
claim includes a service that is assigned status indicator S, T, or V reported on the same claim as the STV- 
packaged service, the payment for the STV-packaged service is packaged into the payment for the service(s) 
with status indicator S, T, V and no separate payment is made for the STV-packaged service. STV-packaged 
services are assigned status indicator Q1. In this case, the code in dispute has a status indicator of QI, meaning 
that it is a STV-packaged service.  This disputed code was billed on the same claim with a code that has a status indicator of S, T, or V.  This means that the code in dispute in this appeal is not separately payable. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 73590 have not been met. Therefore, we decided that the Plan does not have to pay for code 
73590 billed for date of service August 22, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the chemotherapy to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve the chemotherapy. You say that the enrollee has been seen at the current 
facility for 2 years undergoing chemotherapy treatment. You say that this specific facility has been keeping the 
enrollee going and want to have the enrollee have comfort. The Plan denied your request. The Plan says the 
chemotherapy is available in network. 
 
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 chemotherapy 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 tub stool or bench. 
 
You asked the Plan to pre-approve the tub stool or bench. You say that you need this item that can hold 300 
pounds. The Plan denied your request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a tub stool or bench 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 tub stool or bench.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the massage therapy (A9270) provided on 
August 2, 2023. 
 
You asked the Plan to issue reimbursement for this service. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says this service is not covered under 
the wellness allowance benefit.  
 
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 Plans rules for coverage of gym benefits have not been met because the service provided in this case is 
not covered under the wellness allowance benefit. Therefore, we decided that the Plan does not have to issue 
reimbursement for the massage therapy (A9270) provided on August 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections (96361, J1756, J1200, 96365) provided on August 
8, 2023 to August 15, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the injections. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the out-of-network services were not pre-authorized or emergent. 
 
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 injections (96361, J1756, J1200, 96365) provided 
on August 8, 2023 to August 15, 2023, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve endovenous ablation therapy. 
 
You asked the Plan to pre-approve endovenous ablation therapy. You say that these services are covered per 
Medicare guidelines and the medical records provided support the request for the procedure in dispute. The 
Plan denied your request. The Plan says that the requested procedure is for a treatment of a perforator vein, and 
Medicare guidelines say that this procedure is only covered for the treatment of symptomatic varicosities of the 
lesser or greater saphenous veins and their tributaries. The Plan says that the procedure in dispute is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 endovenous ablation therapy. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found that the enrollee has a nonhealing ulcer of the left medial ankle consistent with 
venous stasis. Arterial perfusion has been documented to be satisfactory both by documentation of palpable 
pedal pulses and a normal Ankle-Brachial Index (ABI.) There is documentation that there were failed efforts at 
conservative treatment. While the studies do demonstrate proximal venous occlusive disease at the iliofemoral 
level, there is demonstration of severe reflux in a perforating vein in the territory of the ankle ulcer. After 
reviewing the information, the enrollees provider is recommending ablation of the refluxing perforator vein. 
Although the enrollees proximal occlusive disease may also be contributory, the plan to ablate the refluxing 
perforating vein is reasonable and medically 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 endovenous ablation therapy have been met. Therefore, we decided that the 
Plan has to pre-approve endovenous ablation therapy.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for tennis shoes, foot orthotics provided on October 12, 2022.  
 
You asked the Plan to pay for foot orthotics. You say that you would like reconsideration because the requested 
tennis shoes, foot orthotics 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 pay for tennis shoes, foot orthotics provided on 
October 12, 2022.