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

 
We decided that the Plan does not have to pay for the ambulance services provided by you on the date of service. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. 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 does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on the date of service. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the comprehensive periodontal evaluation (D0180) and 
gingival flap procedure (D4241). 
 
You asked the Plan to pre-approve the comprehensive periodontal evaluation (D0180) and gingival flap 
procedure (D4241). You say that the benefits should be covered under the plan. The Plan denied your request. 
The Plan says out-of-network dental 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 pre-approve the 
comprehensive periodontal evaluation (D0180) and gingival flap procedure (D4241).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided on 
December 6, 2019. 
 
You asked the Plan to pay for genetic testing. You say that the enrollee's treating physician ordered this testing 
to determine if there was a more effective therapy for the enrollee's condition. The Plan denied your request. 
The Plan says the denial of payment for this testing is correct, because this testing was not billed with the 
appropriate coding. 
 
The Plan must follow Medicare rules. Medicare rules say that CGP testing must be billed with CPT code 81479 
for date of service December 6, 2019.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for 
comprehensive genomic profile (CGP) testing provided on December 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an insulin infusion pump. 
 
You asked the Plan to pre-approve the insulin pump. You say that you need an insulin pump because you 
require many daily injections. The Plan denied your request. The Plan says your C-peptide value is not within 
the required range for coverage. 
 
The Plan follows Medicare rules. Medicare rules say that type 2 diabetes patients may be covered for an insulin 
pump when their C-peptide level falls within a certain range.  
 
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 insulin pump. Our reviewer says 
that the criteria for use of this pump have not been met in this case. Our physician reviewer found the patient is 
a 52-year-old female with diagnosed type 2 diabetes mellitus with hyperglycemia and long-term use of insulin. 
She has been using a CGM and injections insulin 3-4 times per day. A1C is 8.9% most recently. C-peptide was 
2.6.  
 
The criteria for an insulin pump include a low C-peptide suggesting low insulin production. However, this 
patient had a normal c-peptide, which does not meet criteria. There was no mention in the records of the patient 
fully implementing aggressive lifestyle changes required for successful control of diabetes. 
 
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 insulin pump have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an insulin infusion pump.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided on 
December 19, 2019. 
 
You asked the Plan to pay for genetic testing. You say that the enrollee's treating physician ordered this testing 
to determine if there was a more effective therapy to treat the enrollee's condition. The Plan denied your 
request. The Plan says the denial of payment for this testing is correct, because this testing was not billed with 
the appropriate coding. 
 
The Plan must follow Medicare rules. Medicare rules say that CGP testing must be billed with CPT code 81479 
for date of service December 19, 2019.  
 
We looked at the file and Medicare rules. This testing was not billed with the appropriate coding. Based on this 
information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we 
decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided on 
December 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve the portable oxygen. You say that you would like reconsideration because 
your doctor ordered you to be on oxygen. The Plan denied your request. The Plan says you have been provided 
with the most appropriate equipment that meets your needs. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a stationary oxygen concentrator. a stationary oxygen concentrator serves the 
same purpose as the portable oxygen. Therefore, we decided that the Plan does not have to pre-approve a 
portable oxygen concentrator.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a CT scan. 
 
You asked the Plan to pre-approve a CT scan. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says that the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CT scan. Our reviewer says that the 
documentation supports that the requested CT scan is medically reasonable and necessary. Our physician 
reviewer found you had a screening low dose chest CT in August 2017. You had a follow up CT of the chest in 
August 2019 to follow-up the lung nodule. The requested CT of the chest is medically necessary and 
reasonable to follow-up the pulmonary nodule. Therefore, you 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 a CT scan have been met. Therefore, we decided that the Plan has to pre-
approve a CT scan.  

 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete maxillary denture provided on January 16, 
2020 by an OON provider. 
 
You asked the Plan to pay for the complete maxillary denture. You say that at the time of the service, the 
enrollee had not received their member card, and were not informed of a particular dentist to go to. The Plan 
denied your request. The Plan says this service was rendered by a non-contracted provider. The Plan also says 
that prior authorization was not obtained. 
 
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 
complete maxillary denture provided on January 16, 2020 by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional routine transportation trips. You say that you need to have 
chemotherapy without a break and need transportation. You say that you have multiple myeloma and are 
currently receiving chronic treatment. You say that you will need rides to the office for as long as the treatment 
is effective. The Plan denied your request. The Plan says the number of trips being requested exceeds the 
benefit allowance for routine transportation services. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 50 trips per year.  
 
We looked at your request, the records in the case file, and the rules. The records show that, at the time of your 
appeal request, you had received 49 one-way routine transportation trips in the 2020 calendar year. This means 
that you have 1 trip remaining of your limited coverage for this type of service. After this 1 remaining routine 
transportation trip is used, your benefit for this type of service will be exhausted. Therefore, we decided that the 
Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pre-approve ambulance transportation for dialysis treatments. 
 
You asked the Plan to pre-approve the ambulance services. The Plan denied your request. The Plan says that 
ambulance transportation is not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance services. Our reviewer 
says that the requested ambulance transportation services are medically reasonable and necessary. Our 
physician reviewer found that the enrollee has a humerus fracture with deconditioning requiring ambulance 
transport to dialysis. The enrollee has severe enough debility that ambulance transport is indicated. 
 
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 ambulance services have been met. Therefore, we decided that the Plan has 
to pre-approve ambulance transportation for dialysis treatments.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical extraction. 
 
You asked the Plan to pre-approve the surgical extraction. You say that the enrollee has discomfort and severe 
periodontal disease. You say that the service will help prevent deteriorating the enrollee's health and a more 
costly dental problem. The Plan denied your request. The Plan says the documentation submitted does not 
support the code requested. 
 
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 surgical 
extraction 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 pre-approve the surgical extraction. Our reviewer 
says that the documentation provided does not indicate that the criteria for coverage for a surgical extraction 
(D7210) for deciduous tooth C has been met. 
 
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 surgical extraction have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the surgical extraction.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an adapter for an amputee for a wheelchair for the 
enrollee. 
 
You asked the Plan to pre-approve the adapter. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not appear to be an amputee. 
 
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 adapter. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found based on the medical records provided there is no documentation that the enrollee has any medical use 
for the requested accessory as there is no documentation that the enrollee is an amputee. 
 
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 adapter have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an adapter for an amputee for a wheelchair for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 testing provided on January 3, 2020. 
 
You asked the Plan to pay for genetic testing. You say that the enrollee's treating physician ordered this testing 
to determine if there was a more effective therapy to treat the enrollee's condition. The Plan denied your 
request. The Plan says the denial of payment for this testing is correct, because this testing was not billed with 
the appropriate coding. 
 
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be billed with CPT 
code 81479 for date of service January 3, 2020.  
 
We looked at the file and Medicare rules. This testing was not billed with the appropriate coding. Based on this 
information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we 
decided that the Plan does not have to pay for Guardant360 testing provided on January 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for advance care planning services provided to the enrollee on 
March 30, 2020. 
 
You asked the Plan to pay for the services. You say that the services were provided through the COVID-19 
pandemic where there was a mandatory stay-at-home order in effect. The Plan denied your request. The Plan 
says 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 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 advance care planning services provided to the 
enrollee on March 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (PCD) coded E0652 
and appliance coded E0667. 
 
You asked the Plan to pre-approve a pneumatic compression device coded E0652 and appliance coded E0667. 
You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the 
requested items are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a pneumatic compression devices coded E0652 are 
only covered for certain indications. 
 
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 a pneumatic compression device coded 
E0652 and appliance coded E0667. Our reviewer says that the documentation does not support that the 
requested pneumatic compression device is medically reasonable or necessary. Our physician reviewer found 
the enrollee 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a pneumatic compression device coded E0652 and appliance coded E0667 have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression 
device (PCD) coded E0652 and appliance coded E0667.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar fusion. 
 
You asked the Plan to pre-approve lumbar fusion. 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 lumbar fusion. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that you have tried physical therapy. You have tried and failed pain management. The 
documentation does not support spinal instability, fracture, or lesion. Therefore, you do 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 lumbar fusion have not been met. Therefore, we decided that the Plan does not 
have to pre-approve lumbar fusion.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on the date of service.

You asked the Plan to waive the copayment for an office visit. You say that you disagree with the charges because you should have a $0 copayment. 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 $15 copayment out-of-network primary care provider visits.

You had an office visit with an out-of-network provider. Therefore, you are responsible to pay the $15 copayment.  

You have been asked to pay a $15 copayment for an office visit. An office visit falls within the physician/practitioner services, including doctor's office visits 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 office visit provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve orthopedic shoe inserts (L3000).

You asked the Plan to pre-approve orthopedic shoe inserts. You say that your doctor recommends these inserts for your foot condition. The Plan denied your request. The Plan says these inserts is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve orthopedic shoe inserts (L3000).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network provider. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are 22 in-network providers within a 20-mile radius of your zip code. 
 
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 provider.