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

 
We decided that the Plan does not have to pre-approve the UVB phototherapy services to be provided by an out 
of network (OON) dermatologist. 
 
You asked the Plan to pre-approve the OON dermatology services. You say that your dermatologist has only 
treated you with creams and shots which only help for a short time and your itching always returns. The Plan 
denied your request. The Plan says review of the record shows that you were seen by the OON provider and the 
phototherapy services were recommended to be provided by a local in-network provider. It was confirmed that 
your network dermatologist can provide the requested treatment. There is no reason noted that only the OON 
provider could provide the necessary care. 
 
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 UVB phototherapy services to be provided by an out of network (OON) dermatologist.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood smear services coded 85060 provided on June 2, 
2020. 
 
You asked the Plan to pay for the blood smear services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services were billed with an inappropriate place of 
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 definition of code 85060 is blood smear, peripheral, interpretation by 
physician with written report. 
 
We find that CPT code 85060 is not supported in the medical record. Specifically, this code was billed with 
place of service 22, on campus-outpatient hospital. The professional/technical component indicator for this 
code is 8. This value identifies the only payment made for the professional component of this code is for 
hospital inpatient. Based on this information, we decided that Medicare rules for coverage of the blood smear 
services have not been met. Therefore, we decided that the Plan does not have to pay for the blood smear 
services coded 85060 provided on June 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an OON 
provider. 
 
You asked the Plan to pre-approve the medical services. You say that you are requesting to continue treatments 
with an out-of-network provider for the remainder of the year. The Plan denied your request. The Plan says 
there is no medical indication for you to be referred out of plan. The Plan states they have appropriate and 
qualified physicians in-plan to treat your allergy condition and you are contractually required to obtain this 
service from 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 
the medical services to be provided by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tradjenta 5 mg tablets. 
 
You asked the Plan to pre-approve the medication. You say that you are requesting review of denial of 
services. The Plan denied your request. The Plan says this is not covered by Medicare or the Plan. 
 
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. This drug is not covered for the enrollee's condition by Medicare or their health plan. 
Therefore, we decided that the Plan does not have to pre-approve Tradjenta 5 mg tablets.  
 
Benefits for the medication 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for vision care services you received from an 
out-of-network provider. 
 
You asked the Plan to waive the coinsurance for the vision care services. You say that you thought that since 
you had authorization, that these services would be paid as in-network. The Plan denied your request. The Plan 
says you were charged this copayment 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 30% 
coinsurance for out-of-network vision care.  
 
You have been asked to pay 30% coinsurance for the vision care services. This cost sharing applies regardless 
of whether you had an authorization or not. 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 coinsurance for vision care 
services you received.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to waive the copayment for the ambulance service provided on January 30, 2020. 
 
You asked the Plan to waive the copayment for the ambulance service. You say that your secondary insurance 
paid the claim so you should not have a copayment. The Plan denied your request. The Plan says that you were 
charged the copayment correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information.  
 
The Plan says you must pay a $240 copayment for each one-way ambulance service. However, the Plan has 
confirmed that your secondary insurance paid the entire balance and is refunding money to the Plan. The Plan 
did not pay this claim. Therefore, we decided that the Plan has to waive the copayment for the ambulance 
service provided on January 30, 2020.  
 
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 core build up (D2950) for teeth # 11, 13, 19 and 31, and 
a root canal (D3310) for tooth # 11. 
 
You asked the Plan to pre-approve the dental services. You say that tooth # 11 has extensive decay. You say 
that tooth # 13 and 19 have recurrent decay. You also say that tooth # 31 has recurrent decay with a large 
amalgam existing restoration. The Plan denied your request. The Plan says core build up is not listed as a 
covered service. The Plan says root canal is not listed as a covered service. The Plan also says if a dental item 
or service is not listed in the benefit chart or listed with NC, then it is not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. The Customer Handbook specifically says if a dental item or service is 
not listed in the benefit chart or listed with NC, then it is not covered. Therefore, we decided that the Plan does 
not have to pre-approve core build up (D2950) for teeth # 11, 13, 19 and 31, and a root canal (D3310) for tooth 
# 11.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral exam (D0120) and prophylaxis (D1110) 
provided on August 13, 2020, by the out of network provider. 
 
You asked the Plan to pay for the dental services. You say that you suffer from multiple chemical sensitivities 
which have progressively gotten worse over time. You state that due to your extensive profile of sensitivities 
you must check any environment to ensure that it is safe for you and the in-network providers do not have 
environments that you can safely be in and that the requested dentist is the only one you could find who had an 
office that you could tolerate and be safely treated in. The Plan denied your request. The Plan says the provider 
in this case is not a network provider. The Plan says services that you receive out of network are not covered. 
 
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 when you receive them out of network. Therefore, we decided that the 
Plan does not have to pay for the periodic oral exam (D0120) and prophylaxis (D1110) provided on August 13, 
2020, by the out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the portable oxygen machine provided on May 8, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for portable oxygen machine. You say that you were told the plan would reimburse 
the purchase. The Plan denied your request. The Plan says prior authorization must be obtained in order to 
receive services from an out-of-network provider. 
 
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 portable oxygen machine provided on May 8, 
2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain fused to noble metal crown (D2752). 
 
You asked the Plan to pre-approve the dental service. The Plan denied your request. The Plan says porcelain 
fused to noble metal crown is not listed as a covered service. The Plan also says if a dental item or service is 
not listed in the benefit chart then it is not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. The Customer Handbook specifically says if a dental item or service is 
not listed in the benefit chart then it is not covered. Therefore, we decided that the Plan does not have to pre-
approve a porcelain fused to noble metal crown (D2752).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MyoPro powered upper extremity range of motion 
device. 
 
You asked the Plan to pre-approve the device. You say that the device is necessary. The Plan denied your 
request. The Plan says the device has not been shown to be a safe and helpful treatment for this diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the medical records provided do not meet the requirements listed in the Social Security Act, 
Section 1862 (a)1(A) and the 42 CFR 411.15(k) for Medicare coverage for the powered upper extremity range 
of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, 
sensors, all components and accessories, custom fabricated (L8702).  At this time the requested robotic orthosis 
is not proven to be more beneficial for treatment of the patient's medical condition/function of hemiparesis after 
stroke than any available standard therapy. The requested device is not the standard of care for hemiparesis 
after a stroke over standard treatment including treatment such as physical and occupational therapy, 
strengthening exercises, constraint induced movement therapy, Botox injections for spasticity. The American 
Heart Association/American Stroke Association discusses electromyographic biofeedback as used in the 
Myopro however there is little evidence in the literature on how well this device would restore muscle strength 
post stroke. The requested device is not reasonable and necessary for the diagnosis or treatment of an illness or 
injury or to improve the functioning of a malformed body member. A review of the literature reveals additional 
controlled studies of the MyoPro Prthosis for upper extremity paralysis after stroke are needed with larger 
patient groups, consistent improvements of relevant outcome functional measures, and long term follow up. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve MyoPro powered upper extremity range of motion device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zolpidem Tartrate 10 MG Tablet. 
 
You asked the Plan to pre-approve the medication. You say that this is recurring medication for the member as 
is the diagnosis. The Plan denied your request. The Plan says this is not covered by Medicare or the Plan. 
 
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. This drug is not covered for the enrollee's condition by Medicare or their health plan. 
Therefore, we decided that the Plan does not have to pre-approve Zolpidem Tartrate 10 MG Tablet.  
 
Benefits for the medication 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: 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 additional routine transportation trips. 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 a covered 
benefit. 
 
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 Plans coverage rules apply in this 
case. The Plan covers a maximum of 40 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the pneumatic compressor (E0652). 
 
You asked the Plan to pre-approve the pneumatic compressor. You say that you would like reconsideration 
because this equipment is medically necessary. The Plan denied your request. The Plan says there was not a 
four-week trial of an E0650 or E0651 and garment. 
 
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 pneumatic compressor. Our 
reviewer says that the requested items/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 meets the Local Coverage Determination criteria for the E0652: Pneumatic compressor, segmental 
home model with calibrated gradient pressure. The prior trial of the standard pump does not include the 
necessary details required by the LCD. 
 
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 pneumatic compressor have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the pneumatic compressor (E0652).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous intraoperative neurophysiology monitoring 
services coded 95940 and the electroencephalogram (EEG) services coded 95955 provided on February 27, 
2020. 
 
You asked the Plan to pay for the continuous intraoperative neurophysiology monitoring services and the 
electroencephalogram (EEG) services. You say that you would like the plan to reconsider their denial. The Plan 
denied your request. The Plan says the services billed are not supported by the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 95940 and 95955 are not supported in the medical record. Specifically, the technical 
report did not include documentation of continuous intraoperative neurophysiology monitoring in the operating 
room, in a one on one monitoring setting requiring personal attendance, for each 15 minutes (listed separately 
in addition to code for primary procedure); therefore, code 95940 cannot be verified. The technical report did 
not include documentation of an electroencephalogram (EEG) during nonintracranial surgery (carotid surgery); 
therefore, code 95955 cannot be verified. Based on this information, we decided that Medicare rules for 
coverage of the continuous intraoperative neurophysiology monitoring services and the electroencephalogram 
(EEG) services have not been met. Therefore, we decided that the Plan does not have to pay for the continuous 
intraoperative neurophysiology monitoring services coded 95940 and the electroencephalogram (EEG) services 
coded 95955 provided on February 27, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. You say that the records provided support the need for 
SNF care. The Plan denied your request. The Plan says the enrollee is not medically stable and needs to stay in 
the hospital. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 SNF services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral 
medications and IV antibiotics. The enrollee had stable vital signs and was transitioning to an oral diet. The 
enrollee received physical therapy in the acute hospital The enrollee was at a stand by assist to minimal assist 
level with functional mobility, including gait to short distances with a rolling walker. There are identifiable 
skilled nursing needs and identifiable skilled therapy needs.  
 
 
 
 
However, these skilled needs are not required on a daily basis. The enrollee does not meet the severity of 
illness or intensity of service criteria for an inpatient basis in a SNF setting. 
 
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 SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home visit provided on April 27, 2020 by an OON provider.You asked the Plan to pay forthe home visit. You say that being under telemedicine does not require an authorization to gain payment for services rendered.The Plan denied your request. The Plan says the service was rendered by a non-network provider. The Plan also says that the service was not approved in advance.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 forthe home visit provided on April 27, 2020 by an OON provider.