Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services rendered. 
 
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 services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for the psychotherapy services 
rendered.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve one additional physical therapy visit for the enrollee. 
 
You asked the Plan to pre-approve the additional visit. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee is at a maintenance level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 additional visit. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found based on the medical records provided, there is no documentation that 
the requested therapy is generally accepted as specific and effective therapy for the enrollees condition. The 
latest therapy notes indicate the enrollee is having very little pain and is golfing with improvement in function 
and discomfort. Based on the available records, the enrollee appears to have plateaued with therapy. Further 
therapy at this point does not appear to be likely to achieve any significant improvement in the enrollee's 
symptoms or functional status. 
 
 
 
 
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 additional visit have not been met. Therefore, we decided that the Plan does 
not have to pre-approve one additional physical therapy visit for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on August 10, 
2020. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you feel that the transfer 
between hospitals was for no reason. The Plan denied your request. The Plan says the claims were processed 
correctly and you are being charged the correct amount. 
 
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 $240 
copayment for ambulance services.  
 
You have been asked to pay a $240 copayment for ambulance services. Ambulance services fall within the 
ambulance services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services 
provided on August 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a generator. 
 
You asked the Plan to pre-approve the generator. You say that your symptoms exacerbate due to extreme 
temperatures. The Plan denied your request. The Plan says the requested item is not a covered benefit, as it not 
primarily for a medical purpose. 
 
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 generator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex interspinous and/or interlaminar 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 medical studies have not proven that this device is helpful for treatment of this health 
problem. 
 
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 this device is considered experimental. More research is needed to show safety and efficacy. 
 
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 Vertiflex interspinous and/or interlaminar device for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MRI of the spinal canal. 
 
You asked the Plan to pre-approve the MRI. You say that you would like reconsideration because the MRI is 
medically necessary and you have been experiencing pain for months. The Plan denied your request. The Plan 
says your doctor did not send medical records to show why you need the scan. 
 
The Plan must follow Medicare rules. Medicare rules say that 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. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the MRI have not been met. Specifically, the documentation submitted does not include any 
clinical information to determine whether Medicare criteria have been met. Therefore, we decided that the Plan 
does not have to pre-approve MRI of the spinal canal.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on May 3, 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 claim was not billed correctly. 
 
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 office setting and should have 
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing 
rendered on May 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on July 28 and August 25, 
2020, by an OON provider. 
 
You asked the Plan to pay for a provider office visit, a biopsy of the tongue, and a tissue pathology. You say 
that you think the provider should be in-network. The Plan denied your request. The Plan says rules for 
payment have not been met. 
 
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 medical services provided on July 28 and 
August 25, 2020, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve the bone anchored hearing aids. 
 
You asked the Plan to pre-approve bone anchored hearing aids. You say that bone anchored hearing aids are 
medically necessary for the enrollee's condition. The Plan denied your request. The Plan says that you do not 
meet the medical criteria for bone anchored hearing aids to be covered. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan pays for 
hearing aids only when medically necessary for your condition. 
 
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 bone anchored hearing aids. Our 
reviewer says that the bone anchored hearing aids are medically necessary. Our physician reviewer found in 
this patient's case, bone anchored hearing aids can be considered medically necessary instead of the standard 
hearing aids or the Plan recommended contralateral routing of signals (CROS) hearing aids. She has tried and 
did not improve with her CROS hearing aids, and she meets audiological criteria for bone anchored hearing 
aids. 
 
We looked at this physician's review, the file, and the Plan's rules. Based on this information, we decided that 
the Plan's rules for coverage of bone anchored hearing aids have been met. Therefore, we decided that the Plan 
has to pre-approve the bone anchored hearing aids.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the application of a lower leg splint billed with CPT code 
29515-RT for date of service May 14, 2020. 
 
You asked the Plan to pay for the application of a lower leg splint. You say that no coding issues were 
identified. The Plan denied your request. The Plan says the services in dispute were considered part of the 
global surgical package of the initial procedure billed by the same provider. 
 
The Plan must follow Medicare rules. Medicare rules say that payment for follow-up visits during the 
postoperative period of the surgery that are related to recovery from the surgery which are provided by the 
physician who performed the surgery, are included in the Medicare approved payment amount for the surgical 
procedure.   
 
We looked at the file and Medicare rules. The records show that the open treatment of a femoral fracture billed 
with CPT code 27236 was performed on April 1, 2020. This procedure has a global surgery period of 90 days. 
The records show that the splint was applied to the right lower extremity and that this service was related to the 
major surgery. The application of the lower leg splint was provided within the 90-day global surgery period for 
the major surgery provided and that payment is included in the Medicare approved payment amount for the 
surgical procedure. Therefore, we decided that the Plan does not have to pay for the application of a lower leg 
splint billed with CPT code 29515-RT for date of service May 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cervical collar provided on February 7, 2020. 
 
You asked the Plan to pay for the cervical collar. You say that this was medically necessary. The Plan denied 
your request. The Plan says that the billed services were not supported. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid relevant medical records which support medical necessity for the supplies 
provided in this case. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for the cervical collar 
provided on February 7, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on July 20, 
2020. 
 
You asked the Plan to waive the copayment for laboratory services. You say that you thought all copayments 
were waived. The Plan denied your request. The Plan says the copayment applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 
copayment per visit for laboratory tests.  
 
You have been asked to pay a $10 copayment for laboratory services. Laboratory services fall within the 
"Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Plan says that only 
copayments for primary care office visits and specialist office visits are being waived. 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 laboratory services provided on July 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve vinyl gloves. 
 
You asked the Plan to pre-approve these services. You say that the out of pocket costs are a financial hardship. 
The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that non-sterile gloves are not covered because they are 
hygienic items that are non-reusable. 
 
We looked at the file and Medicare rules. The services at issue are vinyl gloves. These services are denied by 
Medicare as non-covered. Therefore, we decided that the Plan does not have to pre-approve vinyl gloves.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Bioimpedance Spectroscopy, 8 treatments (93702). 
 
You asked the Plan to pre-approve Bioimpedance Spectroscopy. You say that the enrollee is at high risk of 
developing lymphedema and because of the findings, you believe the use of this device is medically necessary. 
The Plan denied your request. The Plan says the plan considers bioimpedance for the detection of lymphedema 
experimental/investigational and not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Bioimpedance Spectroscopy have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Bioimpedance Spectroscopy, 8 treatments (93702).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional occupational therapy (OT) visits (97168). 
 
You asked the Plan to pre-approve the OT visits. You say that you respectfully request approval for medically 
necessary and appropriate occupational therapy be restored through at least the end of the calendar year as 
recommended. The Plan denied your request. The Plan says the requested services does not meet Medicare 
criteria and 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 OT visits. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested additional therapy is not generally accepted as specific and effective therapy for 
 
 
the enrollees condition. The enrollee has had prior therapy for this condition and it does not appear that the 
enrollees functional level requires the unique skills of a professional therapist to safely and effectively provide 
treatment, or that the services can be safely and effectively performed only by a therapist, or under the 
supervision of a therapist. The enrollee has been instructed in an independent exercise program. The  
specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or 
deliver a program to maintain the patient's current condition or to prevent or slow further deterioration. 
 
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 OT visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 10 additional occupational therapy (OT) visits (97168).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve HORIZANT. You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says self-administered drugs are not covered. 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 HORIZANT. Benefits for these services 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on 
June 16, 2020 by an OON provider. 
 
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that prior to these services 
being rendered, you spoke with a Plan representative and were told that you could see an OON dentist. The 
Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says 
that you are required to utilize in-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.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodic 
oral evaluation and prophylaxis provided on June 16, 2020 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the upper denture (D5215) provided on February 3, 2020. 
 
You asked the Plan to pay for the upper denture. You say that you were informed that your complete dental 
procedure would be covered by your insurance. You say that you do not have a booklet stating what your 
coverage is. You also say that you are on a limited income and would appreciate the bill being covered. The 
Plan denied your request. The Plan says dentures are not listed as 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 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. The record shows that an authorization was approved for the denture 
effective March 12, 2019 to September 19, 2019 under the enrollee's plan which terminated on December 31, 
2019. You did not receive this service in 2019. Therefore, we decided that the Plan does not have to pay for the 
upper denture (D5215) provided on February 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transit securement kit (K0180) for the enrollee. 
 
You asked the Plan to pre-approve the kit. You say that this is medically necessary. The Plan denied your 
request. The Plan says this does not serve a primarily medical purpose. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a transit securement kit (K0180) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve massage therapy. 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. 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. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pre-approve massage therapy.