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

We decided that the Plan does not have to pay for outpatient hospital services provided on January 6, 2020 by
an out of network (OON) provider.
You asked the Plan to pay for outpatient hospital services. You say that you would like these services
reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was
not obtained. The Plan says that the member's primary care physician did not refer 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 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 outpatient hospital services provided on January 6,
2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve paravertebral facet injections. 
 
You asked the Plan to pre-approve paravertebral facet injections. The Plan denied your request. The Plan says 
this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that facet injections are covered when the coverage 
criteria in LCD L35936 are met. 
 
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 paravertebral facet injections. Our 
reviewer says that the requested injections are not medically reasonable and necessary. Our physician reviewer 
found that the provided medical records do not document that the enrollee has satisfied all of the LCD coverage 
requirements. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of paravertebral facet injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve paravertebral facet injections.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a preventative colonoscopy to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve a preventative colonoscopy. You say that you would like approval for these 
services. The Plan denied your request. The Plan says there are in-network providers available for 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 
a preventative colonoscopy to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve custom shoes (foot orthotics). 
 
You asked the Plan to pre-approve foot orthotics. You say that you need custom shoes due to a foot deformity 
which resulted after a surgery. The Plan denied your request. The Plan says the requested items are 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 custom shoes (foot orthotics).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve physician services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve physician services. You say that you were told by two doctors to get another 
opinion. The Plan denied your request. The Plan says there are in-network providers available for these 
physician 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 
physician services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the observation stay provided from March 
13, 2020 to March 16, 2020. 
 
You asked the Plan to waive the copayment for the observation stay. You say that you should not be 
responsible for the copayment because you did not want to be brought to this hospital. The Plan denied your 
request. The Plan says you have been charged the correct cost sharing 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 $300 
copayment per visit for outpatient hospital observation.  
 
You have been asked to pay a $300 copayment for the observation stay. The observation stay falls within the 
Outpatient Hospital Observation 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 
the observation stay provided from March 13, 2020 to March 16, 2020.
Appeal type: Lab
Decision: Favorable

 We decided that the Plan has to hold you harmless for the drug testing services received on February 19, 2020 
minus any cost share requirement amounts. 
 
You asked the Plan to pay for the drug testing services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says that the services received are not a covered benefit. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the drug testing services by a contract provider. The file does not show that the Plan 
provided notice that the drug testing services would not be covered. Under Medicare rules, this means the drug 
testing services is considered approved by the Plan. Therefore, we decided that the Plan has to hold you 
harmless for the drug testing services received on February 19, 2020 minus any cost share requirement 
amounts.  
 
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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a referral to an out-of-network provider for laboratory 
services. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says utilizing an out-of-network provider for routine laboratory testing is denied as not a 
covered benefit. 
 
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 for laboratory services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an office visit (99214, 99204) with a chiropractor. 
 
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 you do not meet criteria for coverage of the requested 
service. 
 
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 pre-approve an office visit (99214, 99204) with a chiropractor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the alveoloplasty in conjunction with extractions - one 
to three teeth per quadrant (D7311). 
 
You asked the Plan to pre-approve the alveoloplasty in conjunction with extractions - one to three teeth per 
quadrant (D7311). You say that your dental situation contributes to poor quality of your overall health. You say 
that the services are essential to improving your overall health and necessary to be able to get dentures. The 
Plan denied your request. The Plan says the service is not a covered benefit. 
 
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 the 
alveoloplasty in conjunction with extractions - one to three teeth per quadrant (D7311).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that this is medically necessary. The Plan denied 
your request. The Plan says this item 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 foot orthotics.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Victoza (J3490). 
 
You asked the Plan to pre-approve the Victoza. You say that you would like reconsideration because this drug 
is medically necessary. The Plan denied your request. The Plan says Medicare Part B does not cover this drug 
for the member's condition. 
 
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 Victoza (J3490).  
 
Benefits for the Victoza 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Freeystlye Libre continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a Freeystlye Libre CGM. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the documentation does not support that you meet 
criteria for the requested device. 
 
The Plan must follow Medicare rules. Medicare rules say that CGM are only covered for certain indications.  
 
We looked at the file and Medicare rules. Review of the file does not support that you perform frequent (four or 
more times a day) testing. Based on this information, we decided that Medicare rules for coverage of a 
Freeystlye Libre CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freeystlye Libre continuous glucose monitor (CGM).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 8-90mg Contrave tablets. 
 
You asked the Plan to pre-approve the Contrave tablets. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the member's drug coverage is limited only 
to those drugs covered under their medical benefit. 
 
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 8-90mg Contrave tablets.  
 
Benefits for the Contrave tablets 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 pre-approve resin-based composites (D2331) for tooth #'s 24, 25, 
and 27. 
 
You asked the Plan to pre-approve the resin-based composites. You say that you are not able to eat and receive 
proper nutrients. You also say that your dentist wants to save your teeth in order for your lower partial to sit 
correctly. The Plan denied your request. The Plan says your resin-based composites benefit has been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, resin-based composites are limited to 
one restoration per tooth, per surface, every 36 months. The record shows that you received resin-based 
composites (D2331) on tooth #'s 24, 25, and 27 on March 9, 2018 and your resin-based composites benefit has 
been exhausted for these teeth. Therefore, we decided that the Plan does not have to pre-approve resin-based 
composites (D2331) for tooth #'s 24, 25, and 27.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network plastic surgeon. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says the medical group approved a referral to in-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 plastic surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair and a security bar. 
 
You asked the Plan to pre-approve the items. You say that this is medically necessary. The Plan denied your 
request. The Plan says these are comfort and convenience items. 
 
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 or security bar 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 shower chair and a 
security bar.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a sleep appliance to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve the OON services. You say that there is no in-network provider that is a 
DME supplier and a dentist. The Plan denied your request. The Plan says the requested service can be 
administered by in-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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve a 
sleep appliance to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Nitro Rollator walker (E1399). 
 
You asked the Plan to pre-approve the Nitro Rollator walker. You say that the rollator is medically necessary. 
The Plan denied your request. The Plan says a heavy duty walker (E0147) with multiple braking system, 
variable wheel resistance, and a seat attachment has already been approved. The requested rollator has 
enhanced features and is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that unique features of gait trainers are not separately 
payable and may not be billed with code E1399.  
 
We looked at the file and Medicare rules. The plan has agreed to cover a Heavy Duty Walker (E0147) with a 
braking system, variable wheel resistance, and a seat attachment. The specific rollator requested has enhanced 
features which are not separately payable, therefore, the rollator requested is not a covered item. Based on this 
information, we decided that Medicare rules for coverage of the Nitro Rollator walker have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Nitro Rollator walker (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a specialist visit provided on December 30, 
2019. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that the office visit was a post-
operative visit due to concerns you had after surgery and you feel that you should not be responsible for the 
charges. 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 $25 
copayment for specialist visits.  
 
The medical records show that you had a specialist visit provided on December 30, 2019. Therefore, you are 
responsible to pay the $25 copayment.  
 
You have been asked to pay a $25 copayment for a specialist visit. A specialist 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 a specialist visit provided on December 30, 2019.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for myocardial perfusion imaging provided on 
February 19, 2020. 
 
You asked the Plan to waive the copayment for myocardial perfusion imaging. You say that you paid the $45 
copayment and are not being billed additional charges. 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 $175 
copayment for advanced radiology services. 
 
You received myocardial perfusion imaging on February 19, 2020. Myocardial perfusion imaging is considered 
an advanced imaging service. Therefore, you are responsible to pay the $175 copayment.   
 
You have been asked to pay a $175 copayment for myocardial perfusion imaging. Myocardial perfusion 
imaging falls within the outpatient diagnostic tests and therapeutic services and supplies 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 myocardial perfusion imaging provided on February 19, 
2020.