Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hospital outpatient clinic visit to be provided by the 
out-of-network provider. 
 
You asked the Plan to pre-approve the hospital outpatient clinic visit. You say that you have been going to this 
facility for over two years and you do not want to be redirected to an in- network orthopedic provider. The Plan 
denied your request. The Plan says you must receive care from in-network providers with the exception of 
emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be 
provided with an in-network provider, which requires prior authorization from the plan. 
 
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 a hospital 
outpatient clinic visit to be provided by the out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve maxillary and mandibular dentures. 
 
You asked the Plan to pre-approve the dentures. You say that you do not agree with this decision. The Plan 
denied your request. The Plan says these services can only be covered once every sixty months. 
 
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 dentures once 
every sixty months (five years). 
 
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 dentures. Our reviewer says that our 
physician reviewer found  
 
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 dentures have not been met. Therefore, we decided that the Plan does not 
have to pre-approve maxillary and mandibular dentures.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 PPE provided on June 20, 2020. 
 
You asked the Plan to pay for the COVID-19 PPE. You say that this was your first dental visit of 2020, and 
more than 6 months since your last dental visit. You also say that this was a visit for a routine checkup and 
cleaning. The Plan denied your request. The Plan says this service is not covered under the Plan. 
 
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 pay for the 
COVID-19 PPE provided on June 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental medication injection (D9612). 
 
You asked the Plan to pre-approve the dental service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says this is not a dental service covered under the 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 pre-approve a 
dental medication injection (D9612).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the eye exam and office visit to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the eye exam and office visit. You say that you would like to go see this 
doctor. The Plan denied your request. The Plan says that a network provider can provide treatment. 
 
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 
the eye exam and office visit to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of intravenous Velcade (bortezomib). 
 
You asked the Plan to pre-approve Velcade. You say that the purpose of this therapy is to reduce the clinical 
effects of neutralizing anti-alglucosidase alpha antibodies that have developed against the recombinant human 
enzyme. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, 
because the long-term safety and efficacy of Velcade for the enrollee's condition has not been firmly 
established in peer-reviewed medical literature. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Velcade. Our reviewer says that the 
enrollee does not meet the Medicare criteria for the use of Velcade. Our physician reviewer found Velcade is 
not Food & Drug Administration (FDA) approved for the treatment of late-onset Pompe disease complicated 
by high enzyme antibody titers to enzyme replacement therapy. The long-term safety and efficacy of Velcade 
for this indication has not been firmly established in peer-reviewed scientific literature. The use of this 
medication is not supported by one of the major drug compendia or by clinical research that appears in a 
Medicare-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Velcade have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of intravenous Velcade (bortezomib).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic parenteral drugs (D9612) received on January 23, 
2020. 
 
You asked the Plan to pay for therapeutic parenteral drugs. You say that you do not agree with the Plan. The 
Plan denied your request. The Plan says rules for payment have not been met. 
 
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 
therapeutic parenteral drugs (D9612) received on January 23, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869). 
 
You asked the Plan to pre-approve the insertion of a Vertiflex device. You say that this is medically necessary. 
The Plan denied your request. The Plan says this is experimental. 
 
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 insertion of a Vertiflex device. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the spacer is 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 insertion of a Vertiflex device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing panel of 22 or more drug classes 
provided on May 27, 2020 billed with code G0483. 
 
You asked the Plan to pay for the definitive drug testing panel. You say that this was billed correctly and 
should be paid. The Plan denied your request. The Plan says the lab report only shows that 20 drug classes 
were tested. There is a more appropriate code to describe this service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual short description of code G0483 is drug test, definitive, 22+ classes. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the definitive drug testing panel. Our 
reviewer says that the lab report does not support the billed code. Our physician reviewer found the medical 
records provided do not include testing of 22 or more drug classes; therefore, this service cannot be verified. 
 
 
 
 
 
 
 
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 definitive drug testing panel have not been met. Therefore, we decided that 
the Plan does not have to pay for the definitive drug testing panel of 22 or more drug classes provided on May 
27, 2020 billed with code G0483.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a backup battery for your CPAP. 
 
You asked the Plan to pre-approve a backup battery. You say that this is needed because your power goes out 
often. The Plan denied your request. The Plan says that this is not covered by Medicare. 
 
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 backup battery for your CPAP.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional critical care services provided on February 10, 
2020. 
 
You asked the Plan to pay for additional critical care services (99292). You say that the Plan should pay this 
claim. The Plan denied your request. The Plan says the services are not supported in the medical record. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99292 is additional block(s) of time, of up to 30 minutes 
each beyond the first 74 minutes of critical care. 
 
We find that CPT code 99292 is not supported in the medical record. Specifically, the record shows 95 minutes 
of critical care time but 105 or more is required. Based on this information, we decided that Medicare rules for 
coverage of additional critical care services have not been met. Therefore, we decided that the Plan does not 
have to pay for additional critical care services provided on February 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Shingrix (Shingles) vaccine. 
 
You asked the Plan to pre-approve Shingrix vaccine. You say that you are appealing for possible coverage of 
the Shingrix vaccine with your primary care provider. The Plan denied your request. The Plan says the Shingrix 
vaccine is not covered under Medicare Part B. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Shingrix (Shingles) vaccine.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental implant removal (D6100), bone replacement 
(D7953), and collection and application procedure (D7921) performed on March 5, 2020, by your dental 
provider. 
 
You asked the Plan to pay for your dental provider's services. You say that your dental provider has been 
successfully treating you for several year and has your full confidence. The Plan denied your request. The Plan 
says your dental provider has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for a dental 
implant removal (D6100), bone replacement (D7953), and collection and application procedure (D7921) 
performed on March 5, 2020, by your dental provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the EKG provided on June 8, 2020. 
 
You asked the Plan to waive the copayment for the EKG. You say that the test was performed in the physician's 
office and the results were given during the visit so the cost should be covered with the office visit. 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 $15 
copayment for diagnostic procedures and tests at an in-network PCP's office.  
 
You have been asked to pay a $15 copayment for the EKG. The EKG falls within the "Outpatient diagnostic 
tests and therapeutic services and supplies" benefit category. The EKG is a diagnostic test, which is considered 
a separate service. 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 EKG provided on June 8, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair power seat elevation system. 
 
You asked the Plan to pre-approve a power wheelchair power seat elevation system. You say that the enrollee 
needs a Group 3 power wheelchair, accessories and power seat elevation system. The Plan denied your request. 
The Plan says power seat elevation systems are not covered by Medicare. 
 
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 power wheelchair power seat elevation system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve alveoloplasty in conjunction with extractions (D7311 x 
2) and a lower overdenture (D5865). 
 
You asked the Plan to pre-approve the dental services. You say that you believe that the enrollee needs these 
services. The Plan denied your request. The Plan says alveoloplasty in conjunction with extractions is not listed 
as a covered service. The Plan says lower overdenture is not listed as a covered service either. 
 
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 
alveoloplasty in conjunction with extractions (D7311 x 2) and a lower overdenture (D5865).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you need LTACH care. The Plan denied 
your request. The Plan says rules for LTACH care have not been met. 
 
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. Our 
physician reviewer found in this case, ongoing care needs include foley catheter care and voiding trials, 
surveillance laboratory studies, 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. 
 
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.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an echocardiography to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve an echocardiography. You say that you would like approval for these 
services with an out-of-network provider. 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 
an echocardiography to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transthoracic echocardiography (TTE) testing. 
 
You asked the Plan to pre-approve TTE test. You say that you are appealing with records. The Plan denied 
your request. The Plan says the denial of authorization for this service is correct, because this TTE testing 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 TTE test. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has no symptoms of aortic stenosis and his examination does not suggest 
significant aortic stenosis. His echocardiogram done in August 2018 revealed "slight" aortic stenosis with a 
mean valve gradient of 10mmHg, an aortic velocity of 2.1m/s, and a calculated valve area of 1.8cm2. His 
ejection fraction was normal at 65% at that time as well. In the absence of symptoms or signs of aortic stenosis 
by history or exam, and since he has only previously documented mild aortic stenosis, follow-up 
echocardiography is recommended only every 3 to 5 years based on published guidelines and criteria. 
Therefore, since the enrollee's last echocardiograph was less than 3 years ago, this does not meet the Medicare 
criteria for appropriate recommended frequency of the requested service for the clinical situation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TTE test have not been met. Therefore, we decided that the Plan does not have 
to pre-approve transthoracic echocardiography (TTE) testing.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says you have used 10 of the 12 allotted routine 
transportation trips for the 2020 benefit year. 
 
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 12 one-way transportation trips per year.  
 
We looked at your request, the records in the case file, and the rules. The file shows that you have used 10 one-
way trips this year. This means that you have 2 one-way trips remaining and you will have exhausted this 
benefit for the 2020 benefit year. Therefore, we decided that the Plan does not have to pre-approve additional 
routine transportation.