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 June 22, 2020 by an out of 
network provider. 
 
You asked the Plan to pay for outpatient rehabilitative services. You say that the Plan should pay this claim. 
The Plan denied your request. The Plan says you did not request 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 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 outpatient rehabilitative services provided on 
June 22, 2020 by an out of network provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health aide services. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this requires a prior authorization and an assessment. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or 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 services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found in this case, the 
documentation doesn't support that you require skilled nursing services or skilled rehab services to provide 
treatment that is medically necessary. You do not require skilled nursing or rehab services to effectively 
provide treatment, care, and/or services in order to improve the member's condition, perform a maintenance 
program to maintain your condition and/or prevent deterioration. You have been medically stable without any 
recent exacerbations of chronic medical problems or hospitalizations. You have been receiving 24-hour home 
health aide services without any skilled needs. The care you have been receiving is custodial in nature and 24-
hour aide services are 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve home health aide services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740) for tooth #14 and core buildup, 
including any pins when required (D2950) for tooth #14. 
 
You asked the Plan to pre-approve the crown and core buildup. You say that you grind your teeth at night, 
which has damaged your teeth. The Plan denied your request. The Plan says these services exceed the 
maximum count allowed per period. 
 
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, crown (D2740) and core buildup, 
including any pins when required (D2950) are each limited to one procedure per tooth every five plan years. 
The record shows that you received a crown and core buildup on tooth #14 on May 5, 2016, and your crown 
(D2740) and core buildup, including any pins when required (D2950) benefits for tooth #14 have been 
exhausted. Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) for tooth #14 
and core buildup, including any pins when required (D2950) for tooth #14.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a walker purchased online on June 30, 
2020. 
 
You asked the Plan to pay for this walker. You say that the Plan should pay for this walker. The Plan denied 
your request. The Plan says this walker was purchased without prior authorization and from a provider is not 
Medicare eligible. 
 
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 provider who is not a Medicare eligible provider. This walker was 
purchased without prior authorization from an ineligible retail provider. You did not follow the Plan contract 
rules when purchasing this equipment. Therefore, we decided that the Plan does not have to pay for a walker 
purchased online from on June 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller with harness and electronic 
connection for a power wheelchair (PWC). 
 
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 covered. 
 
The Plan must follow Medicare rules. Medicare rules say that an expandable controller with harness is used to 
operate three or more actuators. The rules say that a power tilt and recline seating system and power leg 
elevation feature come with their own power switches. 
 
We looked at the file and Medicare rules. The file does not show that the expandable controller with harness 
are needed to operate the approved power options through a joystick. The electronic connection is not needed 
because the approved power options have their own approved power switches. 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 an expandable controller with harness and electronic connection for a power 
wheelchair (PWC).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete upper denture (D5110) complete lower 
dentures (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing because you need new 
dentures due to running your dentures over with your wheelchair. The Plan denied your request. The Plan says 
this request exceeds the benefit maximum. 
 
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. This service is covered once 
every five years. The records show that you received this service on January 23, 2019. 
 
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 
complete upper denture (D5110) complete lower dentures (D5120).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of a Superion interspinous stabilization 
device (22869, 22870). 
 
You asked the Plan to pre-approve this service. You say that this service is medically necessary as the enrollee 
has lumbar spinal stenosis. The Plan denied your request. The Plan says this service 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 this service. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the device 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 this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the insertion of a Superion interspinous stabilization device (22869, 22870).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the gel pressure mattress. 
 
You asked the Plan to pre-approve the gel pressure mattress. You say that you would like reconsideration 
because you were advised to request a mattress for your condition. The Plan denied your request. The Plan says 
the information submitted does not show that you are not able to move or that you have pressure ulcers. 
 
The Plan must follow Medicare rules. Medicare rules say that a Group 1 mattress overlay or mattress is covered 
if specific criteria are met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the gel pressure mattress have not been met. Specifically, the record does not show that you are 
completely immobile, have limited mobility, have pressure ulcers or have a qualifying condition. Therefore, we 
decided that the Plan does not have to pre-approve the gel pressure mattress.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Oscillating Lung Expansion Device and supplies. 
 
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 covered. 
 
The Plan must follow Medicare rules. Medicare rules say that an IPV is not covered by Medicare. 
 
We looked at the file and Medicare rules. The services at issue are an IPV. These services are not covered by 
Medicare for use in the home setting. Therefore, we decided that the Plan does not have to pre-approve an 
Oscillating Lung Expansion Device and supplies.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the heart with a 
quantitative evaluation of coronary calcium (75571). 
 
You asked the Plan to pre-approve a CT scan of the heart with a quantitative evaluation of coronary calcium. 
You say that this is necessary to know how much plaque is forming on your heart. The Plan denied your 
request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that quantitative calcium scoring is not a covered 
service and will be denied as not medically necessary. 
 
We looked at the file and Medicare rules. The requested service is excluded from coverage. Based on this 
information, we decided that Medicare rules for coverage of a CT scan of the heart with a quantitative 
evaluation of coronary calcium have not been met. Therefore, we decided that the Plan does not have to pre-
approve a computed tomography (CT) scan of the heart with a quantitative evaluation of coronary calcium 
(75571).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services (99152) provided on January 
22, 2020. 
 
You asked the Plan to pay for the moderate sedation services. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says the documentation submitted did 
not indicate the presence of an independent trained observer to assist in the monitoring if the patient's level of 
consciousness and physiological status. 
 
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 99152 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older 
 
We find that CPT code 99152 is not supported in the record. Specifically, the record does not indicate the 
presence of an independent trained observer. Based on this information, we decided that Medicare rules for 
coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan does not 
have to pay for the moderate sedation services (99152) provided on January 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve seven additional skilled nursing home health visits. 
 
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan 
denied your request. The Plan says the provider can reassess in four weeks for more visits. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 visits. Our reviewer says 
that the requested visits are not medically reasonable or necessary. Our physician reviewer found in this case 
that the documentation doesn't support that you require additional skilled nursing services to provide treatment 
that is medically necessary. You do not require additional skilled nursing or rehab services to effectively 
provide treatment, care, and/or services in order to improve your condition, perform a maintenance program to 
maintain your condition and/or prevent deterioration. You have been medically stable without any recent 
exacerbations of chronic medical problems or hospitalizations. The additional two visits should be adequate for 
patient education and if additional visits are requested then a new request can be made. 
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 visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve seven additional skilled nursing home health visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture (D5214). 
 
You asked the Plan to pre-approve the mandibular partial denture. You say that you never picked up your 
denture from the first provider. You also say that you did not think the denture was ever coming in, so you 
went to a new provider to try getting another denture made. The Plan denied your request. The Plan says 
dentures can be made every 96 months. The Plan also says that you have received a partial or full denture in the 
last 96 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, mandibular partial denture (D5214) is 
limited to one every 96 months. The record shows that you received a mandibular partial denture (D5214) on 
May 27, 2020, and your mandibular partial denture (D5214) benefit has been exhausted. Therefore, we decided 
that the Plan does not have to pre-approve a mandibular partial denture (D5214).  
 
Your complaint about your dissatisfaction with your previous provider is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-
network provider. 
  
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says with 
limited exceptions, while you are a member of our plan you must use network providers to get your medical 
care and services. The only exceptions are emergencies, urgently needed services when the network is not 
available (generally, when you are out of the area), out-of-area dialysis services, and cases in which the Plan 
authorizes use of out-of-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 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 to be provided by the out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar transforaminal epidural injections. 
 
You asked the Plan to pre-approve lumbar transforaminal epidural injections. You say that that you are in pain. 
The Plan denied your request. The Plan says the information provided does not include any recent conservative 
management. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The record does not show 4 weeks of medication and physical 
therapy. Based on this information, we decided that Medicare rules for coverage of lumbar transforaminal 
epidural injections have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar 
transforaminal epidural injections.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve an alpha-feto-protein blood analysis and magnetic resonance 
imaging (MRI) of the abdomen while out of area. 
 
You asked the Plan to pre-approve the alpha-feto-protein blood analysis and the MRI of the abdomen. You say 
that your health is declining and that your family cannot get you home until your condition stabilizes. You say 
that you have been making frequent trips to the emergency room. The Plan denied your request. The Plan says 
that the services which remain in dispute are not urgent or emergent and are being requested for outside of the 
enrollee's chosen medical group. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis, and 
pre-approved care.   
 
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 alpha-feto-protein blood analysis 
and the MRI of the abdomen. Our reviewer says that the criteria for coverage out of area have been met. Our 
physician reviewer found the enrollee was diagnosed with cryptogenic cirrhosis and was outside of her home 
area when requiring two thoracenteses, in addition to experiencing variceal bleed. The occurrence of liver 
decompensation is not a foreseeable event that precludes coverage.  There was no evidence that the enrollee 
had decompensated disease at the time of leaving her service area.  Appropriate imaging and screening for 
hepatocellular carcinoma is medically necessary in a patient with liver disease, particularly when recurrent 
pleural effusions are encountered.  A delay in imaging can lead to more advanced disease that could preclude 
effective therapeutic intervention. 
 
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 alpha-feto-protein blood analysis and the MRI of the abdomen have been 
met. Therefore, we decided that the Plan has to pre-approve an alpha-feto-protein blood analysis and magnetic 
resonance imaging (MRI) of the abdomen while out of area.  
 
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 pay for the complete maxillary denture and complete mandibular 
denture provided on August 4, 2020 by an OON provider. 
 
You asked the Plan to pay for the complete dentures. You say that you were not aware that you had to use your 
$2,500 dental benefits at a specific network. The Plan denied your request. The Plan says these services were 
rendered by an OON provider. The Plan also says that services performed by an OON provider are not covered 
because your healthcare plan does not have OON 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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the 
complete maxillary denture and complete mandibular denture provided on August 4, 2020 by an OON 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services provided by the out-of-network 
provider. 
 
You asked the Plan to pre-approve the physician's services. 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 
physician's services provided by the out-of-network provider.