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

 
We decided that the Plan does not have to pay for the medical services provided on August 10, 2020, by an out-
of-network provider. 
 
You asked the Plan to pay for the medical services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the provider is out-of-network with the member's Plan, the services were not 
approved in advance and the services were not urgent or emergent. 
 
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 medical services provided on August 10, 2020, 
by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the lesion excision (D7411) and deep sedation (D9222 
and D9223). 
 
You asked the Plan to pre-approve the lesion excision (D7411) and deep sedation (D9222 and D9223). You say 
that you need the tumor removed so you can find out if its benign or cancerous. You say that this should be 
covered under the oral surgery benefit. The Plan denied your request. The Plan says the services are not 
covered benefits. 
 
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 the 
lesion excision (D7411) and deep sedation (D9222 and D9223).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve human leukocyte antigen (HLA) Class II typing 
(81376). 
 
You asked the Plan to pre-approve HLA Class II typing. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that  antigen leukocyte cellular antibody testing is 
considered experimental and investigational for allergy testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of HLA Class II typing have not been met. Therefore, we decided that the Plan does not have to pre-
approve human leukocyte antigen (HLA) Class II typing (81376).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on August 12, 
2020 by an OON provider. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that the enrollee could not choose 
an in-network primary care physician, and your doctors are the only providers who will treat the enrollee's for 
primary care. You also say that there is currently no in-network doctor who can treat the patients at this facility. 
The Plan denied your request. The Plan says the service was rendered by a non-participating provider. The Plan 
also says that prior authorization was not obtained. 
 
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 
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 subsequent nursing facility care provided on 
August 12, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve out of network physician services. 
 
You asked the Plan to pre-approve out of network physician services. You say that you prefer to see the 
requested provider. The Plan denied your request. The Plan says the requested provider is not in network. 
 
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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide these services and has provided you with the names of those providers. We found no 
exception that would require the Plan to pre-approve out of network providers. Therefore, we decided that the 
Plan does not have to pre-approve out of network physician services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation. 
 
You asked the Plan to pre-approve the requested services. You say that her pain under control will enable the 
enrollee to complete her activities of daily living. The Plan denied your request. The Plan says the enrollee did 
not have 50% improvement in her ability to perform previously painful movements. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint interventions are only covered under 
certain medical indications. 
 
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 requested services. Our physician 
reviewer found that the enrollee has chronic right low back pain. She had one set of diagnostic medial branch 
blocks (MBBs), which gave her 40% pain relief. Coverage criteria requires two sets of diagnostic MBBs which 
produce 80% pain relief. Here only 40% pain relief was achieved in a single diagnostic set of blocks. 
Therefore, the criteria are not met, and the request is considered 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and dental cleaning 
(D1110) provided on October 28, 2020, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the periodic oral evaluation and dental cleaning. You say that you did not find a 
provider in your network and would like this claim reprocessed. The Plan denied your request. The Plan says 
services need to be provided in network to be eligible for payment. 
 
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. The Plan covers the periodic 
oral evaluation and dental cleaning when the services are received from a contracted provider with the Plan.  
 
We looked at the file and Medicare rules. 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. Based on this information, we decided that the Plan's rules for coverage of the periodic 
oral evaluation and dental cleaning have not been met. Therefore, we decided that the Plan does not have to pay 
for the periodic oral evaluation (D0120) and dental cleaning (D1110) provided on October 28, 2020, by an out-
of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for enteral formula provided from September 10, 2020, to November 27, 
2020. 
 
You asked the Plan to pay for the enteral formula. You say that the Plan should pay for the enteral formula. The 
Plan denied your request. The Plan says that prior authorization was not requested until after the service was 
rendered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the enteral formula by a contract provider. The file does not show that the Plan provided 
notice that the enteral formula would not be covered. Under Medicare rules, this means the enteral formula is 
considered approved by the Plan. Therefore, we decided that the Plan has to pay for enteral formula provided 
from September 10, 2020, to November 27, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve this item. You say that a home ventilator is medically necessary for the 
enrollee. The Plan denied your request. The Plan says a home ventilator is not medically necessary as the 
record does not show that the enrollee has chronic respiratory failure. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 this item. Our reviewer says that a 
home ventilator is not medically necessary. Our physician reviewer found that the records do not include 
documentation of CO2 retention when the patient is in a stable state. Obstructive sleep apnea and obesity-
hypoventilation syndrome have not been excluded. A BiPAP device has not been tried. Medicare does not 
cover a home ventilator when used as a BiPAP. A home ventilator is not medically 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 this item have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient office visit (99214) 
radiologic examination (70360) provided October 22, 2020. 
 
You asked the Plan to waive the copayment for the urgent care services. You say that you were told from the 
urgent care that you would not have a copay or have to pay anything since you had your Medicare card. The 
Plan denied your request. The Plan says this claim was processed and the correct copayment was applied per 
the Evidence of Coverage. 
 
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 $50 
copayment for each urgent care visit.  
 
You have been asked to pay $50 copayment for each urgent care visit. The urgent care 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 the 
outpatient office visit (99214) radiologic examination (70360) provided October 22, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Coflex lumbar interspinous decompression device (CPT 
Code 22867). 
 
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 is experimental and investigational. 
 
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 Coflex device is experimental. More research is needed to show safety and efficacy. There 
is no documented spinal instability. Hardware is not needed. 
 
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 Coflex lumbar interspinous decompression device (CPT Code 22867).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a protective outer surface covering and Comfort Flex 
Style Socket for a prosthesis. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the requested Comfort Flex Style 
Socket does not have FDA approval. The services are not safe and effective and are considered 
experimental/investigational by Medicare. The services are therefore not medically necessary. 
 
The records do not support that the enrollee is exposed to harsh conditions and does not engage in 
extraordinary activities that require extra protection from a specialized prosthetic cover. It cannot be covered as 
a standard prosthetic cover. The services are not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a protective outer surface covering and Comfort Flex Style Socket for a prosthesis.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Onivyde (J9205) for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that off-label use is medically accepted when there is evidence in or more of the 
compendia or in the medical literature that it works for the disease in question. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 drug. Our reviewer says that the 
requested drug is medically reasonable or necessary. Our physician reviewer found the medical records 
provided evidence that the use of this medication was medically necessary by the requesting provider. Given 
the failure of other means of palliation, it is medically reasonable to try this as palliative therapy. 
 
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 drug have been met. Therefore, we decided that the Plan has to pre-approve 
Onivyde (J9205) for the enrollee.  
 
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 a mandibular partial denture (D5226). 
 
You asked the Plan to pre-approve the denture. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered service. 
 
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 
mandibular partial denture (D5226).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on July 6, 
2020. 
 
You asked the Plan to pay for the limited oral evaluation (D0140). You say that you want to know why your 
dental needs aren't covered by the $2,000 granted by the plan. The Plan denied your request. The Plan says a 
limited exam to evaluate a problem has a frequency limit of one procedure per plan year.  
 
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 Plan also has a maximum benefit 
of one limited oral exam every year. The Plan paid for a limited oral evaluation provided on January 2, 2020, 
which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the limited oral 
evaluation (D0140) provided on July 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on March 10, 
2020.  
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says it has been determined that the claim for the services provided on March 10, 2020 was 
processed correctly. Procedure code 00350 was denied as a duplicate service to the referring claim number by 
the exact same provider for the same date of service. The records reviewed do not support the service being 
performed by the billing provider more than once for this date of service.  Medicare billing criteria were not 
met.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case the claim submitted cannot be paid as 
billed as it is a duplicate to previously billed services. Medicare billing criteria are not met. Therefore, we 
decided that the Plan does not have to pay for physician services provided to the enrollee on March 10.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for durable medical equipment purchased by the enrollee from 
July 7, 2020, to August 13, 2020 from an online commercial retailer.  
 
You asked the Plan to pay for this equipment. You say that this equipment should be covered by the Plan due 
to Covid 19. The Plan denied your request. The Plan says this equipment is not covered by Medicare when 
provided by a supplier who is not a Medicare eligible provider. 
 
The Plan must follow Medicare rules. Medicare does not pay for equipment from commercial retailers online 
who are not Medicare eligible providers. Medicare does not pay for self-help devices or shower chairs. The 
Plan contract says that durable medical equipment requires prior authorization. The enrollee purchased 
equipment online without prior authorization. The enrollee did not follow the Plan contract rules when they 
purchased this equipment. Covid 19 would not have hindered the Plans ability to provide this equipment to the 
enrollee within the rules of the contract. Therefore, we decided that the Plan does not have to pay for durable 
medical equipment purchased by the enrollee from July 7, 2020, to August 13, 2020 online.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement scooter. 
 
You asked the Plan to pre-approve the replacement scooter. You say that you would like reconsideration 
because this equipment is medically necessary. The Plan denied your request. The Plan says the member's 
scooter is less than 5 years old and there is no documentation that the scooter has been lost or irreparably 
damaged. 
 
The Plan must follow Medicare rules. Medicare rules say that in no case can the reasonable useful lifetime of 
DME be less than 5 years. Replacement due to wear is not covered during the reasonable useful lifetime of the 
equipment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the replacement scooter have not been met. Specifically, the record indicates that the member's 
scooter is less than 5 years old. There is no evidence in the documentation that the member's scooter has been 
lost or irreparably damaged. Therefore, we decided that the Plan does not have to pre-approve a replacement 
scooter.