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

 
We decided that the Plan does not have to pre-approve proton beam therapy. 
 
You asked the Plan to pre-approve proton beam therapy. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has 
not been met. 
 
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 proton beam therapy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found to date, there are no compelling data to suggest that proton therapy is superior to or 
more beneficial than intensity-modulated radiation therapy/image-guided radiation therapy (IMRT/IGRT). The 
generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, 
and to not routinely offer it to patients. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam therapy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that it is not expected that the enrollee will need three weeks of 
further treatment and that his care can be managed in a lower level. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Long term 
acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide 
clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing 
care needs include respiratory support including ventilator and tracheostomy care, intravenous antibiotics, 
surveillance laboratory studies, tube feedings, and therapy services. The documentation does not support that 
the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where 
he is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet 
Medicare criteria for LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care facility visit (99214) on 
January 30, 2020. 
 
You asked the Plan to waive the copayment for an urgent care facility visit. You say that you suspect the 
copayment being charged to be fraudulent. The Plan denied your request. The Plan says the correct copayment 
was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for each covered office visit to providers other than your primary care provider for urgently needed 
services.  
 
You have been asked to pay a $40 copayment for an urgent care facility visit. An urgent care facility visit falls 
within the urgently needed 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 
an urgent care facility visit (99214) on January 30, 2020.  
 
Your complaint about being unable to contact the billing office of the urgent care facility is not a valid appeal 
for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare 
does not permit us to make a decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eyelid surgery for the enrollee. 
 
You asked the Plan to pre-approve eyelid surgery. You say that this surgery is medically necessary. The Plan 
denied your request. The Plan says Medicare coverage criteria are not met. 
 
The Plan must follow Medicare rules. Medicare has specific coverage criteria for this type of surgery.  
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 eyelid surgery. Our reviewer says that 
Medicare coverage criteria are not met. Our reviewer found based on the medical records the enrollee does not 
fully meet the criteria as stated above for this type of surgery. The submitted photographs do not demonstrate 
low-lying eyelid margins that would be expected to interfere with vision or the visual field, or cause difficulty 
reading due to upper eyelid drooping, looking through the eyelashes or seeing the upper eyelid skin. Medicare 
coverage criteria are not met.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of eyelid surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve eyelid surgery for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested physician's services. 
 
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says that 
the Plan only covers care from in-network providers with the exception of emergency or urgent care, or if the 
care cannot be provided with an in-network provider. There are contracted providers who can 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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the 
requested physician's services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the urgent care services rendered on April 
29, 2020. 
 
You asked the Plan to waive the copayment for these services. You say that you were unaware of the charges. 
The Plan denied your request. The Plan says the copayment was 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 $65 
copayment per visit for Medicare-covered urgently needed services. 
 
Review of the file shows that you received urgent care services on April 29, 2020. Per the contract with the 
Plan, there is a $65 copayment per visit for Medicare-covered urgently needed services. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed 
amount for these services was $53.92. Given that the allowed amount was less than the $65 copayment, you 
have been asked to pay $53.92 for these services. 
 
Therefore, we decided that the Plan does not have to waive the copayment for the urgent care services rendered 
on April 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient office visit for the evaluation 
and management of an established patient (99214) provided April 30, 2020. 
 
You asked the Plan to waive the copayment for the outpatient office visit. You say that when you went the first 
time you were told it would be a $15 copay and now you have received a bill for an additional $30. You think 
it is unfair having to pay any copays due to your financial circumstances. The Plan denied your request. The 
Plan says this claim was processed correctly per the plan benefits. 
 
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 $45 
copayment per visit for covered services to a medical facility or urgent care center. for Urgently needed 
services.  
 
You have been asked to pay $45 copayment per visit for covered services to a medical facility or urgent care 
center. for the outpatient office visit. the outpatient office visit falls within the Urgently needed 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 the outpatient office visit for the evaluation and 
management of an established patient (99214) provided April 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve K4 advanced lower limb prosthesis features (L5930, 
L5830, L5968, L5973). 
 
You asked the Plan to pre-approve the advanced prosthesis features. You say that the advanced features are 
medically necessary. The Plan denied your request. The Plan says the requested features exceed the enrollee's 
needs and abilities. 
 
The Plan follows Medicare rules. Medicare rules say that K4 features are covered when the enrollee has the 
need and ability or potential for prosthetic ambulation that exceeds basic ambulation skills, exhibiting high 
impact, stress, or energy levels. 
 
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 advanced prosthesis features. Our 
reviewer says that the requested advanced features are not medically necessary. Our physician reviewer found a 
Letter of Medical Necessity notes that the enrollee is a candidate to receive a K3 Microprocessor knee and foot. 
A Daily Note/Billing Sheet Addendum documents that the enrollee is a K3 level ambulator. Documentation 
does not support that the K4 advanced prosthesis features (L5930, L5830, L5968, L5973) are medically 
reasonable and necessary, based on the enrollee's functional abilities. At the current time, the enrollee is a 
typical community ambulator. 
 
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 advanced prosthesis features have not been met. Therefore, we decided that 
the Plan does not have to pre-approve K4 advanced lower limb prosthesis features (L5930, L5830, L5968, 
L5973).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on December 17, 
2019. 
 
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says 
that the Plan requires utilization of network providers when possible and available, and requires authorization 
for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency 
situation, has been documented.   
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for subsequent nursing facility care provided on December 17, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 14, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, 
however, the physician must clearly document, in the medical record, his or her intent that the test be 
performed. 
 
We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the 
medical record. We find that the issue of intent is not clear. There are no medical records in the case file in 
regards to the physicians intent that the test be performed prior to services taking place. Furthermore, the CPT 
codes being appealed are collected as a blood specimen via venipuncture. The labs in the case file indicate the 
specimen received was urine.  
 
 
 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on January 14, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6531 that 
were issued on March 13, 2020. 
 
You asked the Plan to pay for the compression stockings. You say that you require the stockings to improve 
circulation and overall health. The Plan denied your request. The Plan says the stockings are not covered when 
they are not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6531 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
 
 
 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. 
Therefore, we decided that the Plan does not have to pay for the compression stockings identified with code 
A6531 that were issued on March 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ophthalmology visit provided on May 
19, 2019. 
 
You asked the Plan to waive the copayment for the ophthalmology visit. You say that you should not have to 
pay for these services. The Plan denied your request. The Plan says that the copay was 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 $40 
copayment for each visit to a specialist, such as an ophthalmologist or optometrist, for Medicare-covered 
benefits.  
 
You have been asked to pay a $40 copayment for the ophthalmology visit. The ophthalmology visit falls within 
the visit to a specialist, such as an ophthalmologist or optometrist, for Medicare-covered benefits 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 ophthalmology visit provided on May 19, 
2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for reimbursement of your 2019 fitness benefit. 
 
You asked the Plan to pay for the reimbursement. You say that evidence of your contract should be proof 
enough. The Plan denied your request. The Plan says in order for a wellness reimbursement request to be 
considered complete, you must provide all of the documents requested on the reimbursement form, such as 
proof of payment and an itemized bill. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. The Plan covers gym benefits 
up to $150 a year. 
 
The Plan?s rules for coverage of gym benefits have not been met because you have not submitted proof of 
payment for the gym services. Therefore, we decided that the Plan does not have to pay for reimbursement of 
your 2019 fitness benefit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eye wear (V2200) provided by an out-of-network (OON) 
provided on January 30, 2020. 
 
You asked the Plan to pay for OON eye wear. You say that the provider you purchased glasses from is less 
expensive than network providers. The Plan denied your request. The Plan says eye wear from OON providers 
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 these services when received from a plan Vision provider. 
 
 
 
 
 
 
We looked at the file and the Plan's rules. The provider you purchased glasses from is not a network provider. 
Based on this information, we decided that the Plan's rules for coverage of OON eye wear have not been met. 
Therefore, we decided that the Plan does not have to pay for eye wear (V2200) provided by an out-of-network 
(OON) provided on January 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation (D9310) and retreatment of previous root 
canal therapy (D3348) provided on January 15, 2020. 
 
You asked the Plan to pay for the consultation and retreatment of previous root canal therapy. You say that 
endodontics are covered at 50% based on your benefit information. You also say that you were not informed 
that second root canals would not be covered. The Plan denied your request. The Plan says these services are 
not covered benefits under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
consultation (D9310) and retreatment of previous root canal therapy (D3348) provided on January 15, 2020.  
 
Your complaint about being misled by your benefits guide is not a valid appeal for medical coverage. This part 
of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services (90837) provided from July 18, 
2019 to December 19, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for OON psychotherapy services. You say that you originally billed Medicare for 
these services and did not know authorization was required. The Plan denied your request. The Plan says these 
services were not authorized. 
 
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 psychotherapy services (90837) provided from 
July 18, 2019 to December 19, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prostate biopsy (G0416) provided on February 20, 2020. 
 
You asked the Plan to pay for the prostate biopsy. You say that you would like reconsideration because the 
number of units rendered and billed were necessary to evaluate and treat the patient's condition. The Plan 
denied your request. The Plan says the billed units are exceeding the allowed MUE. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code G0416 is 1. You billed 2 units of this code, exceeding the MUE. Based on 
this information, we decided that Medicare rules for coverage of the prostate biopsy have not been met. 
Therefore, we decided that the Plan does not have to pay for the prostate biopsy (G0416) provided on February 
20, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on January 10, 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 there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing 
rendered on January 10, 2020.