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

 
We decided that the Plan does not have to pre-approve a core buildup, including any pins when required 
(D2950). 
 
You asked the Plan to pre-approve the core buildup. You say that the enrollee needs this service to restore and 
save the tooth. The Plan denied your request. The Plan says this service is not covered under the enrollee's 
benefit 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 pre-approve a 
core buildup, including any pins when required (D2950).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided by a participating 
provider on November 6, 2020. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you always have this done at the 
doctor's request. You say that this should be covered entirely. 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 $50 
copayment for outpatient diagnostic tests/ultrasound/in-network.  
 
You have been asked to pay a $50 copayment for an ultrasound. The correct copayment has been applied to the 
services that were provided. An ultrasound falls within the outpatient diagnostic tests/ultrasound/in-network 
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 ultrasound provided by a 
participating provider on November 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee does not 
need an intensive therapy program with multiple visits per week from a rehab physician. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 IRF care. Our physician reviewer found 
that the enrollee was admitted to the acute hospital or diarrhea, nausea, and vomiting and was treated for a 
gastrointestinal ulcer. Her medical problems are stable. There are no complex nursing needs. The enrollee does 
not require treatment by multiple therapies in an intensive rehabilitation therapy program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be 
provided at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for peripheral vascular 
disease treated with angioplasty. The enrollees medical problems are stable. There are no complex nursing or 
rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that this patient will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition 
does not meet Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial upper denture with a flexible base (D5225) and 
a partial lower denture with a flexible base (D5226). 
 
You asked the Plan to pre-approve the dental items. You say that these services should be part of your dental 
coverage. The Plan denied your request. The Plan says partial upper denture is not listed as a covered service. 
The Plan says that partial lower denture is not listed as a covered service. The Plan also says that any services 
not listed are not 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 pre-approve a 
partial upper denture with a flexible base (D5225) and a partial lower denture with a flexible base (D5226).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shoulder elbow wrist hand orthosis (L3960). 
 
You asked the Plan to pay for the shoulder elbow wrist hand orthosis. You say that this item was medically 
necessary for the enrollee. The Plan denied your request. The Plan says documentation did not contain 
evidence of a relationship with the ordering physician. 
 
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 pay for the shoulder elbow wrist hand orthosis. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found a physical examination of the shoulder would reasonably be required to 
adequately assess whether the shoulder/arm orthosis was medically necessary for an enrollee. The 
documentation does not support that the orthosis was medically reasonable and necessary for the enrollee in 
this case, as there is insufficient documentation of a credible physical examination of the shoulder. 
 
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 shoulder elbow wrist hand orthosis have not been met. Therefore, we 
decided that the Plan does not have to pay for the shoulder elbow wrist hand orthosis (L3960).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the molecular pathology procedure (81479) provided on 
October 8, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the pathology procedure. You say that this was a medically necessary service and 
should be covered. The Plan denied your request. The Plan says they do not cover out of network services, 
except in limited circumstances. These services were not urgent or pre-approved. 
 
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 molecular pathology procedure (81479) 
provided on October 8, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab tests provided on September 30, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for lab tests. 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. 
 
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 tests provided on September 30, 2020 by an 
out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve the total electric hospital bed. You say that you would like reconsideration 
because you are not able to go up the stairs or sleep on the couch after your knee surgery. The Plan denied your 
request. The Plan says there is no clinical evidence to support the medical necessity for a fully electric hospital 
bed. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve the total electric 
hospital bed (E0265).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that you are appealing this denial. The 
Plan denied your request. The Plan says the denial of authorization for these items is correct, because these 
compression stockings are not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6549.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on September 24, 2020. 
 
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent 
or emergent, nor were they approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
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 psychotherapy services provided on September 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the panoramic x-ray (D0330), the initial periapical 
x-ray (D0220), and the additional periapical x-ray (D0230) provided on October 13, 2020. 
 
You asked the Plan to reimburse you for the panoramic x-ray and the periapical x-rays. You say that you found 
this practice on the website. You say that the office assigned you a provider that was not in network. You say 
that you feel that you were manipulated and taken advantage of by the dental office. You also say that the 
dental office should not be listed as in network on the website unless all the providers specifically identified as 
being in network. The Plan denied your request. The Plan says the provider in this case is out of network. The 
Plan says that contracts exist with individual dentists and not facilities. The Plan says that panoramic x-ray is 
not listed as a covered service. The Plan also says that periapical x-rays are not listed as covered services. 
 
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 reimburse you for 
the panoramic x-ray (D0330), the initial periapical x-ray (D0220), and the additional periapical x-ray (D0230) 
provided on October 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist 
device. 
 
You asked the Plan to pre-approve a powered upper extremity range of motion assist device (L8702). You say 
that this device would restore function to the dysfunctional arm and the ability to perform activities of daily 
living. The Plan denied your request. The Plan says the orthosis is still being studied to establish clinical 
effectiveness and long-term safety of the device. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. There is insufficient medical record information submitted to show 
this orthosis would be preferred or more effective than the traditional upper orthosis types that are covered by 
Medicare. The requested limb orthosis continues to be denied because of insufficient evidence of its 
effectiveness. Based on this information, we decided that Medicare rules for coverage of a powered upper 
extremity range of motion assist device (L8702) have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a powered upper extremity range of motion assist device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMs device. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee needs this device due to his 
worsening heart failure. The Plan denied your request. The Plan says the effectiveness of the device has not 
been demonstrated in the peer-reviewed literature. 
 
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 requested services. Our physician 
reviewer found that the enrollee has a diagnosis of chronic diastolic congestive heart failure, hypertension, 
atrial fibrillation, and lymphoma. The efficacy of the CardioMEMS heart failure system remains uncertain at 
this time. Further clinical study is needed to determine the efficacy and safety of this 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMs device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic x-ray, two surgical extractions, and inhalation 
of nitrous oxide/analgesia provided on March 17, 2020. 
 
You asked the Plan to pay for the panoramic x-ray, two surgical extractions, and inhalation of nitrous 
oxide/analgesia. You say that these services were provided due to an emergency medical procedure. The Plan 
denied your request. The Plan says these services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 
panoramic x-ray, two surgical extractions, and inhalation of nitrous oxide/analgesia provided on March 17, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that you are hoping to get the enrollee the best care. 
The Plan denied your request. The Plan says there is no documentation as to why the services cannot be 
performed 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 medical 
services to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), bitewing x-ray, single radiographic image (D0270), and an intraoral-periapical, first radiographic image (D0220).

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that benefits are not available for procedures performed by out of network providers.

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.

We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of these services have not been met. Specifically, the dental services were performed by an out-of-network provider. The Plan contract states that members must select, and be assigned to, a dental administrator contracted dental office to utilize covered benefits. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), bitewing x-ray, single radiographic image (D0270), and an intraoral-periapical, first radiographic image (D0220).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mastectomy bra.

You asked the Plan to pre-approve the bra. You say that you have received this with no issue since 2011. The Plan denied your request. The Plan says the replacement request is prior to the life expectancy for this item.

The Plan must follow Medicare rules. Medicare rules say that the useful lifetime expectancy for silicone breast prostheses is two years. 

You last received a mastectomy bra less than two years in 2019. Based on this information, we decided that Medicare rules for coverage of the bra have not been met. Therefore, we decided that the Plan does not have to pre-approve a mastectomy bra.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve myocardial perfusion imaging to be provided by an out-of-
network (OON) provider.

You asked the Plan to pre-approve the OON myocardial perfusion imaging. You say that the clinical
documentation provided supports the need for myocardial perfusion imaging. The Plan denied your request.
The Plan says the enrollee's care must be received from a network provider. The Plan says that there are in
network providers who can supply the service in dispute.

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
myocardial perfusion imaging to be provided by an out-of-network (OON) provider.