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

 
We decided that the Plan does not have to pay for physician's services provided on October 8, 2019 and 
November 5, 2019. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization.  
 
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 
physician's services. 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 physician's services provided on October 8, 2019 and 
November 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefluoride carries.You asked the Plan to pre-approvethe dental service. You say that the enrollee was referred by their head and neck surgeon after being diagnosed with squamous cell carcinoma on thebase of their tongue. You say that this service is needed as a result of high doses of radiation to the enrollee's head and neck. You also say that this treatment is medically necessary.The Plan denied your request. The Plan says the dental treatment is not related to extraction prior to radiation or a facial fracture.Medicare generally does not cover dental services. The Plan follows the same rule.Although the Plan has supplemental dental coverage, the services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pre-approvefluoride carries.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ultrasounds provided on January 30, 2020. 
 
You asked the Plan to waive the copayment for ultrasounds. You say that you feel that you are being 
overcharged and disagree with 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 $135 
copayment for each radiological diagnostic service. 
 
You received two ultrasounds on January 30, 2020. Therefore, you are responsible to pay the total allowed 
amount of $227.18, which is less than the total copayment amount.   
 
You have been asked to pay the total copayment amount of $227.18 for ultrasounds. Ultrasounds fall 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 ultrasounds provided on January 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services for an infectious agent detection by 
nucleic acid (dna or rna); severe acute respiratory syndrome coronavirus 2 (sars-cov-2) and endoscopic 
retrograde cholangiopancreatography (ercp); with removal of foreign body(s) or stent(s) from biliary/pancreatic 
duct. 
 
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says the 
enrollee 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 
physician's services for an infectious agent detection by nucleic acid (dna or rna); severe acute respiratory 
syndrome coronavirus 2 (sars-cov-2) and endoscopic retrograde cholangiopancreatography (ercp); with 
removal of foreign body(s) or stent(s) from biliary/pancreatic duct.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a spinal canal injection provided on June 
10, 2020. 
 
You asked the Plan to waive the copayment for a spinal canal injection. You say that the surgery was 
authorized so you thought that it would be covered. 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 $600 
copayment for outpatient hospital services.  
 
You have been asked to pay the allowed amount of $573.22, which is less than the $600 copayment for a spinal 
canal injection. A spinal canal injection falls within the outpatient hospital 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 a spinal canal injection provided on June 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain crown (D2740) for tooth # 2. 
 
You asked the Plan to pre-approve the dental service. You say that the crown on tooth # 2 is missing. You also 
say that full coverage is needed. The Plan denied your request. The Plan says crowns are covered once per 
tooth, per 60 months. The Plan says that the frequency limit for a crown on tooth # 2 has been reached. 
 
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 and crowns are a covered service, the 
frequency limit has been reached. The record shows that the Plan paid for a crown for tooth # 2 on March 15, 
2017. Therefore, we decided that the Plan does not have to pre-approve a porcelain crown (D2740) for tooth # 
2.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you would like reconsideration because you 
need this equipment in order to continue taking showers. The Plan denied your request. The Plan says Durable 
Medical Equipment items that do not primarily serve a medical purpose and which are not reasonable and 
necessary to treat an illness or injury are not covered under any condition. 
 
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 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.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional occupational therapy visits. 
 
You asked the Plan to pre-approve the additional occupational therapy visits. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says the additional 
visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 additional occupational therapy 
visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent 
deterioration of the enrollee's condition. Our physician reviewer found the member does not need the 
specialized skill, knowledge and judgment of a qualified therapist to establish, design and/or deliver a program 
to maintain the patient's current condition or to prevent or slow further deterioration. 
 
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 additional occupational therapy visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve 8 additional occupational therapy visits.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray services coded 71045 provided on April 20, 2020. 
 
You asked the Plan to pay for the x-ray services. 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 payable. 
 
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 71045 is radiologic examination, chest; single view. 
 
We find that CPT code 71045 is not supported in the medical record. Specifically, this service is an exact 
duplicate to a previously submitted and processed claim. Based on this information, we decided that Medicare 
rules for coverage of the x-ray services have not been met. Therefore, we decided that the Plan does not have to 
pay for the x-ray services coded 71045 provided on April 20, 2020.
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 the 
services requested are not emergent and can be provided by a 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Guardian Sensor 3 CGM. 
 
You asked the Plan to pre-approve the Guardian Sensor 3 CGM. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says the Guardian Sensor 3 CGM is a 
non-covered benefit. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have Dexcom G5. Dexcom G5 serves the same purpose as the Guardian Sensor 3 
CGM. Therefore, we decided that the Plan does not have to pre-approve Guardian Sensor 3 CGM.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya (J3245). 
 
You asked the Plan to pre-approve Ilumya. You say that the enrollee has tried and failed Humira. The Plan 
denied your request. The Plan says step therapy criteria have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Ilumya. Our reviewer says that the 
criteria for coverage of Ilumya have not been met. Our physician reviewer found the Plan requires a trial of 
Stelara before they will approve the requested drug. Based on the medical records provided there is no 
indication that the enrollee has tried Stelara or that Stelara would likely be less effective or have adverse effects 
for the patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ilumya have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Ilumya (J3245).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a life alert necklace. 
 
You asked the Plan to pre-approve a life alert necklace. The Plan denied your request. The Plan says this is not 
a covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that telephone alert systems are non-covered because 
they are emergency communications systems and do not serve a diagnostic or therapeutic purpose.  
 
We looked at the file and Medicare rules. Per the referenced NCD, the requested life alert necklace is not a 
covered benefit, as it does not serve a diagnostic or therapeutic purpose. Based on this information, we decided 
that Medicare rules for coverage of a life alert necklace have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a life alert necklace.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac (SI) joint injection. 
 
You asked the Plan to pre-approve the SI joint injection. The Plan denied your request. The Plan says this 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 the SI joint injection. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there is no documentation of any positive exam findings of SI joint dysfunction and 
documentation of any trial of aggressive conservative therapy such as, physical therapy or home exercise for a 
period of 4-6 weeks. The requested sacroiliac joint injection is not medically reasonable or necessary. 
 
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 SI joint injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a sacroiliac (SI) joint injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two mandible jaw bone grafts and two maxillary jaw 
bone grafts. 
 
You asked the Plan to pre-approve the bone grafts. You say that the enrollee will benefit from oral surgery to 
correct malocclusion that is related to functional impairment that cannot be improved with routine dental or 
orthodontic therapy by reconstruction of the mandible and maxilla. The Plan denied your request. The Plan 
says you will be providing the bone graft in preparation for dental implants. The Plan also says that dental 
appliances are not a covered benefit by the Plan, nor are procedures provided for the care, treatment or 
replacement of teeth or structures directly supporting the teeth. 
 
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 two 
mandible jaw bone grafts and two maxillary jaw bone grafts.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgently needed services provided on 
February 7, 2020 to February 8, 2020. 
 
You asked the Plan to waive the copayment for urgently needed services. You say that you paid your 
copayment and disagree with the 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 $35 
copayment for urgently needed services provided at an urgent care center.  
 
You received urgently needed services on February 7, 2020 and February 8, 2020. Therefore, you are 
responsible to pay a $35 copayment per each visit. The total amount you owe is: $70.  
 
You have been asked to pay the total copayment amount of $70 for urgently needed services. Urgently needed 
services fall 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 urgently needed services provided on February 7, 2020 to February 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network provider. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says physician's services must be provided by 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 provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the clinical crown lengthening (D4249) provided on June 16, 
2020. 
 
You asked the Plan to pay for the dental service. You say that the dentist had to cut your gum to expose the 
cavity and repair it. You also say that this service was part of the repair of tooth # 28 which was scheduled for 
August. The Plan denied your request. The Plan says clinical crown lengthening is not listed as a covered 
service. The Plan also says that any services not listed 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, clinical crown lengthening is not 
among those listed as covered under this benefit. The Evidence of Coverage clearly states that any services not 
listed are not covered. Therefore, we decided that the Plan does not have to pay for the clinical crown 
lengthening (D4249) provided on June 16, 2020.
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 you would like the plan to reconsider their 
denial. 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 the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's 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 pay for the Apixaban, 5 mg tablet, the Carvedilol, 3.125 mg tablet, 
and the Asprin, 81 mg tablet, provided while you were in an outpatient setting.
 
You asked the Plan to pay for the self-administered drugs. You say that you were charged $50.12 for self-
administered drugs that you received while you were in the hospital. The Plan denied your request. The Plan 
says the drugs that you were provided are considered to be self-administered. The Plan says you have a medical 
only policy, not a Prescription Drug Plan. The Plan also says self-administered drug coverage is limited to 
Medicare Part B covered drugs. 
 
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 pay for the Apixaban, 5 mg tablet, the 
Carvedilol, 3.125 mg tablet, and the Asprin, 81 mg tablet, provided while you were in an outpatient setting.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.