Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve specialist services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve specialist services. You say that you would like to continue to see this 
doctor. You say that you do not want to start over with a new doctor. The Plan denied your request. The Plan 
says there are in-network providers available to provide these services. 
 
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 
specialist 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 routine eye exam provided. 
 
You asked the Plan to pay for an eye exam. You say that this should be a covered service. The Plan denied 
your request. The Plan says you have already used your supplement benefit and therefore this service is not 
covered. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers one non-Medicare covered routine vision exam, including dilation and refraction as 
necessary. 
 
 We looked at the file and the Plan's rules. The documentation indicates you already utilized your one non-
Medicare covered routine vision exam and therefore the vision exam provided, is not 
covered. Based on this information, we decided that the Plan's rules for coverage of eye exam have not been 
met. Therefore, we decided that the Plan does not have to pay for the routine eye exam provided.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Abraxane. 
 
You asked the Plan to pre-approve Abraxane. You say that the enrollee has cancer and needs chemotherapy to 
live. The Plan denied your request. The Plan says the information submitted does not meet the Plan's medical 
necessity guidelines for coverage. 
 
 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Abraxane. Our reviewer says that 
Abraxane is not medically reasonable and necessary for the enrollee. Our physician reviewer found the enrollee 
has not tried and failed the required drug(s), Taxol and Taxotere. Our reviewer found that the Plan?s required 
drug(s) would not likely be less effective and/or likely have adverse effects for the enrollee. Our physician 
reviewer also found that the documentation does not show that the enrollee has a contraindication to drugs used 
to treat any hypersensitivity. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Abraxane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Abraxane.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation and 19 extractions to be provided by an 
oral surgeon. 
 
You asked the Plan to pre-approve the consultation and extractions. You say that you need these services 
provided before you get heart disease. The Plan denied your request. The Plan says dental services are only 
covered when they are performed by a participating general dentist. The Plan also says that dental services 
performed by an oral surgeon 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 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 
covered when they are received by anyone other than a participating general dentist. Therefore, we decided that 
the Plan does not have to pre-approve a consultation and 19 extractions to be provided by an oral surgeon.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for audiologic function tests (92557, 92567) provided on 
February 7, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the audiology services. You say that the provider informed you that your office 
visits were not covered due to no referral. At the time you did not know you needed one. In March you went to 
your primary care doctor and requested one. The Plan denied your request. The Plan says enrollee's 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 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 has network providers 
available who can provide 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 audiologic function tests (92557, 92567) provided 
on February 7, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar orthosis (L0457) provided to the enrollee on June 
12, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not indicate services are necessary for treatment of the 
enrollee's condition. 
 
The rules say for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. When conducting a review of a 
covered DME item, ordered by a physician, the contractor shall ensure that the physician saw the beneficiary 
and conducted a face-to-face assessment.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the durable medical equipment have not been met. Specifically, medical records do not support a 
prior face-to-face examination with the ordering physician within 6 months of ordering the DME or an 
appropriate use of telehealth. The submitted consultation notes do not support that a physical examination was 
performed. The information submitted does not confirm that Medicare coverage criteria have been met. 
Therefore, we decided that the Plan does not have to pay for a lumbar orthosis (L0457) provided to the enrollee 
on June 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99203) provided on July 10, 2020. 
 
You asked the Plan to pay 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 a covered benefit under 
your contractual policy or by Medicare. 
 
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 pay for the office visit (99203) provided on July 10, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the continued SNF stay provided from January 20, 2020, to 
January 21, 2020. 
 
You asked the Plan to pay for the continued SNF stay. The Plan denied your request. The Plan says the SNF 
stay was not reasonable and necessary under Medicare guidelines. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 continued SNF stay. Our reviewer says 
that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did 
not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled 
professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, 
knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing 
and/or skilled therapy on an inpatient basis in a SNF setting. 
 
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 continued SNF stay have not been met. Therefore, we decided that the Plan 
does not have to pay for the continued SNF stay provided from January 20, 2020, to January 21, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by you on April 20, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that this should be the members responsibility. 
The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctor?s office is not a covered destination.  
 
The services you have asked the Plan to pay for are ambulance transport services to a doctor?s office. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided by you on April 
20, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the crowns (D2740) for teeth # 26, 27, 28 and 29. 
 
You asked the Plan to pay for the dental services. You say that the decision to get crowns was not for cosmetic 
reasons, but for functionality. The Plan denied your request. The Plan says that the damage on these teeth was 
caused from attrition, abrasion, abfraction, or erosion. The Plan also says crowns are not covered in this 
situation. 
 
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 the dental 
services when the services are medically necessary and reasonable. 
 
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 dental services. Our reviewer says that 
the crowns were medically necessary. Our physician reviewer found the provided documentation indicates that 
these teeth are severely broken down. The reviewer found that restoration with crowns is medically reasonable 
and necessary in order to restore these teeth to adequate masticatory function. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have been met. Therefore, we decided that the Plan has to 
pay for the crowns (D2740) for teeth # 26, 27, 28 and 29.  
 
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 pre-approve a bath/shower chair. 
 
You asked the Plan to pre-approve the chair. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is considered a comfort/convenience item. 
 
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 shower chair 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 bath/shower chair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on June 3, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says screening tests are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the laboratory services rendered on June 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network facility. 
 
You asked the Plan to pre-approve these services. You say that the enrollee has hand pain radiating to the arm. 
The Plan denied your request. The Plan says the services are available from network providers. 
 
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 
a referral to an out-of-network facility.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Livalo (J8499), 2 mg tablet. 
 
You asked the Plan to pre-approve Livalo. You say that the enrollee has been on samples. You say that the 
previous authorization was denied. You say that since then, the enrollee has sampled 3 statins, Crestor, 
Simvastatin, and Lipitor. You also say that the enrollee has myalgia with all 3 of them. The Plan denied your 
request. The Plan says the requested drug is considered self-administered. The Plan says self-administered 
drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not 
covered under 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 Livalo (J8499), 2 mg tablet.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on June 27, 2020 to July 
23, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for home health services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services 
rendered by an out-of-network 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 has network providers 
available who can provide 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 home health services provided on June 27, 
2020 to July 23, 2020 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 core buildup, including any pins when required for tooth 
#21 provided on July 9, 2020. 
 
You asked the Plan to pay for the core buildup. The Plan denied your request. The Plan says you have met your 
$1,000 annual maximum benefit. 
 
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 Plan offers a $1,000 annual dental 
benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are 
responsible for the full charges of any additional dental services. The record shows that you met the annual 
maximum benefit while processing the claim for the July 9, 2020 date of service, and your annual maximum 
benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the core buildup, 
including any pins when required for tooth #21 provided on July 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, 
E2377, E2313) for the enrollee. 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says it is not medically necessary to control the three approved power options through 
the joystick (drive interface). 
 
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 accessories. Our reviewer says that 
the requested accessories are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation does not reveal that the enrollee requires other types of proportional input 
devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-
proportional input devices (e.g., sip and puff, head array, etc.). The enrollee does not need to operate 3 or more 
powered seating actuators through the drive control, a separate display (i.e., for alternate control devices),other 
electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive 
control), or an attendant control. The enrollee's upper extremity strength and function are sufficient for the 
enrollee to operate any power options through their own switches. 
 
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 accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional power wheelchair accessories (E2311, E2377, E2313) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two core buildups, including any pins when required and 
pontic provided on June 15, 2020. 
 
You asked the Plan to pay for the core buildups and pontic. You say that you contacted the Plan and were told 
that partial dentures were covered under the enrollee's policy. The Plan denied your request. The Plan says 
these services 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 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 two 
core buildups, including any pins when required and pontic provided on June 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0652). 
 
 
 
You asked the Plan to pay for a pneumatic compression device. You say that the enrollee requires the device. 
The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic 
pump that Medicare requires. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device 
(E0652).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered from September 6, 2019 to 
November 13, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claims were billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an outpatient rehabilitation 
setting and should have been billed with POS code 21. Therefore, we decided that the Plan does not have to 
pay for the laboratory services rendered from September 6, 2019 to November 13, 2019.