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

 
We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network 
provider on October 15, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network 
provider on October 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the scaling in presence of generalized moderate or severe 
gingival inflammation (D4346) provided on November 13, 2020. 
 
You asked the Plan to pay for the scaling. You say that you believe this service should be covered. The Plan 
denied your request. The Plan says this service is not a covered benefit 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 Plan's 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 
scaling in presence of generalized moderate or severe gingival inflammation (D4346) provided on November 
13, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve knee surgery to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the knee surgery. The Plan denied your request. The Plan says the services 
are 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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve knee 
surgery to be provided by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve interlaminar/interspinous device. 
 
You asked the Plan to pre-approve interlaminar/interspinous device. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
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 interlaminar/interspinous device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has chronic low back pain. There is a lack of large volume, 
long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition. 
Food and Drug Administration (FDA) indications include implantation of the Superion device at one or two 
adjacent lumbar levels in patients with moderate spinal stenosis in whom operative treatment is indicated at no 
more than two levels, from L1 to L5. The enrollee has multiple degrees of spinal stenosis, many not at FDA 
indicated levels of moderate spinal stenosis. FDA contraindications include spinal instability, scoliosis, 
obesity, and osteoporosis, and have not been adequately addressed in the medical records. Therefore, the 
enrollee does not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of interlaminar/interspinous device have not been met. Therefore, we decided that 
the Plan does not have to pre-approve interlaminar/interspinous device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Superion interspinous spacer device. 
 
You asked the Plan to pre-approve the spacer device. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
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 the spacer device. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the Superion spacer is experimental. More research is needed to show safety and efficacy 
of the device. 
 
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 spacer device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Superion interspinous spacer device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on June 25, 2020. 
 
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the 
services were billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.  
 
We looked at the file and Medicare rules. The documentation shows that the services in question were billed 
with POS code 81. However, the records indicate that the specimen was collected in an office setting, which 
would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based 
on this information, we decided that Medicare rules for coverage of the drug testing services have not been 
met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on June 25, 
2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient mental health services. 
 
You asked the Plan to pre-approve the services. The Plan denied your request. The Plan says this provider does 
not participate in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. A pastoral counselor is not eligible to enroll in the Medicare program. Therefore, we decided that the 
Plan does not have to pre-approve outpatient mental health services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on July 13, 2020, by an OON provider. 
 
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan 
denied your request. The Plan says prior authorization was not obtained by a participating provider. The Plan 
says that the referring provider is not a participating provider. 
 
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 lab work provided on July 13, 2020, by an OON 
provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic mammogram provided by a 
participating hospital on September 18, 2020. 
 
You asked the Plan to waive the copayment for a diagnostic mammogram. You say that you thought this was a 
screening. The Plan denied your request. The Plan says the correct copayment has been applied. 
 
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 $100 
copayment for outpatient diagnostic tests/diagnostic tests/outpatient hospital facility.  
 
You have been asked to pay $72.66 which is less than your copayment amount of $100 for a diagnostic 
mammogram. Since a diagnostic mammogram was provided, the correct copayment has been applied. A 
diagnostic mammogram falls within the outpatient diagnostic tests/diagnostic tests/outpatient hospital facility 
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 a diagnostic mammogram 
provided by a participating hospital on September 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the preventive procedure and two additional intraoral 
periapical x-rays, and does not have to pay more for the comprehensive oral evaluation, first intraoral 
periapical x-ray, bitewing x-rays, panoramic x-ray, and prophylaxis provided on November 24, 2020 by an 
OON provider. 
 
You asked the Plan to pay for the preventive procedure and two additional intraoral periapical x-rays, and pay 
more for the comprehensive oral evaluation, first intraoral periapical x-ray, bitewing x-rays, panoramic x-ray, 
and prophylaxis. You say that you would like these services to be covered. The Plan denied your request. The 
Plan says the preventive procedure is not a covered benefit. The Plan also says that your intraoral x-rays benefit 
has been satisfied and the frequency limitation has been exceeded. The Plan also says that these services were 
performed by a non-participating provider, and you are responsible for any difference between the Maximum 
Allowable Fee and the amount the provider bills you for the services. 
 
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, unspecified preventive procedure is not 
among those covered under this benefit. The contract says that intraoral x-rays are limited to one procedure per 
calendar year. The record shows that you received a first intraoral periapical x-ray on November 24, 2020, and 
your intraoral x-rays benefit has been exhausted. The contract also says that you are responsible for the 
difference between the billed amount and allowed amount for services that are received OON. The record also 
shows that you did not contact the Plan prior to this date of service to verify the provider's network status.  
 
 
Therefore, we decided that the Plan does not have to pay for the preventive procedure and two additional 
intraoral periapical x-rays, and does not have to pay more for the comprehensive oral evaluation, first intraoral 
periapical x-ray, bitewing x-rays, panoramic x-ray, and prophylaxis provided on November 24, 2020 by an 
OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) and 
intraoral - periapical first radiographic image (D0220) provided December 8, 2020. 
 
You asked the Plan to pay for the limited oral evaluation and intraoral periapical x-rays. You say that you 
would like the Plan to cover the services. The Plan denied your request. The Plan says you have exceeded 
frequency limits for the services at issue and therefore they are not covered under your benefits. 
 
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. The Plan covers oral 
evaluations twice a year and intraoral periapical x-rays once a year.  
 
We looked at the file and Medicare rules. The Plan provided evidence that oral evaluations were covered in 
February 2020, and June 2020. An intraoral periapical x-ray was covered in February 2020. Based on this 
information, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused 
(D0140) and intraoral - periapical first radiographic image (D0220) provided December 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete mandibular denture. 
 
You asked the Plan to pre-approve the complete mandibular denture. You say that you lost your denture and 
need a new one approved. The Plan denied your request. The Plan says your mandibular denture benefit has 
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, you are limited to one upper complete 
and one lower complete denture every five years. The record shows that you received a complete mandibular 
denture on January 7, 2020 and your complete mandibular denture benefit has been exhausted. Therefore, we 
decided that the Plan does not have to pre-approve a complete mandibular denture.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the occlusal guard (D7880) provided on November 4, 2020. 
 
You asked the Plan to pay for the dental item. You say that you were told that you had dental benefits for the x-
rays. You say that the retainer should be covered. You say that it was made due to severe osteoporosis and 
bone loss. You say that you if it is not covered under dental, then your medical coverage should. You also say 
that you cannot pay this bill. The Plan denied your request. The Plan says occlusal guard is not listed as 
covered. 
 
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, the occlusal guard is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the occlusal guard 
(D7880) provided on November 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs LTACH services. The 
Plan denied your request. The Plan says the enrollee can safely receive care in another setting such as a skilled 
nursing facility. 
 
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 there is no documentation provided necessitating admission to a LTACH. The 
enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at 
the LTACH that are not available at the acute care hospital where the enrollee is currently receiving care. 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 health plan. 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 long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Coflex device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says large population sufficiently powered randomized controlled trials that demonstrate 
long-term health outcome advantages are needed. 
 
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 the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the Coflex device is experimental. More research is needed to show safety and efficacy of the device. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Coflex device for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Icosapent Ethyl. 
 
You asked the Plan to pre-approve Icosapent Ethyl. You say that the enrollee's trig numbers need to be 
lowered. The Plan denied your request. The Plan says this drug is intended for patient self-administration. The 
Plan also says that this drug is not covered for the enrollee's condition by Medicare Part B. 
 
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 Icosapent Ethyl.  
 
Benefits for Icosapent Ethyl 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Otezla. 
 
You asked the Plan to pre-approve Otezla. You say that the enrollee cannot do self-injections, and has a 
difficult time with transportation. The Plan denied your request. The Plan says this drug is intended for the 
enrollee's self-administration. The Plan also says that this drug is not covered for the enrollee's condition by 
Medicare Part B. 
 
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 Otezla.  
 
Benefits for Otezla 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says the dispensing plan 
meets for Part D coverage, the pharmacy dispenses the drug to the member to self-administer, or to take it to 
the provider. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Prolia.  
 
Benefits for Prolia may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.