Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve immediate lower partial dentures, and complete upper dentures. 
 
You asked the Plan to pre-approve the requested dentures. You say that you are in pain and cannot wait any 
longer. The Plan denied your request. The Plan says your benefit limit has been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
The file shows that immediate lower dentures and complete upper dentures were requested. We looked at the 
file, and Medicare rules. The plan has already approved upper and lower dentures. Your plan only covers 
dentures once every 5 years. Based on this information, we decided that the Plan's rules for coverage of the 
requested dentures have not been met. Therefore, we decided that the Plan does not have to pre-approve 
immediate lower partial dentures, and complete upper dentures.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a special group 3 power wheelchair with features. 
 
You asked the Plan to pre-approve the power wheelchair. You say that the device is medically necessary. The 
Plan denied your request. The Plan says you are currently at a skilled nursing facility (SNF).  Medicare DME 
benefit does not cover DME in a SNF therefore a power wheelchair is never covered at your present location.  
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the power wheelchair is being requested for use in a SNF or hospital.  Therefore, we decided 
that the Plan does not have to pre-approve a special group 3 power wheelchair with features.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services (D0120, D1110) provided July 28, 2020. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered. The Plan denied 
your request. The Plan says dental services are only covered when received from contracted providers. 
 
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. Dental services obtained from out-of-network providers are not 
covered. Therefore, we decided that the Plan does not have to pay for dental services (D0120, D1110) provided 
July 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection of more than 7 skin lesions (11901) provided on 
February 18, 2020. 
 
You asked the Plan to pay for the injections. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the documentation does not support the service billed. 
 
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 11901 is injection, intralesional; more than 7 lesions. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the injections. Our reviewer says that CPT code 11901 does 
not meet criteria for billing or reimbursement consideration. Our reviewer found the documentation does not 
show that more than 7 lesions were injected, therefore this procedure cannot be confirmed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injections have not been met. Therefore, we decided that the Plan does not 
have to pay for the injection of more than 7 skin lesions (11901) provided on February 18, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (80061) provided August 28, 2019. 
 
You asked the Plan to pay for the lab services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the service cannot be paid as billed. 
 
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 code 80061 is not supported in the medical record. Specifically, this service was billed with 
the GY modifier. The GY modifier must be used when suppliers want to indicate that the item or supply is 
statutorily non-covered or is not a Medicare benefit. A Based on this information, we decided that Medicare 
rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to 
pay for lab services (80061) provided August 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on July 6, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says the services were 
available 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The 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. The Plan did not pre-approve the services 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 July 6, 2020 by an out of network (OON) 
provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0428) provided on September 16, 
2020. 
 
You asked the Plan to pay for the ambulance services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says these services were not medically 
necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the ambulance services. Our reviewer says 
that the non-emergent ambulance services were not medically necessary. Our physician reviewer found the 
member did not need contact isolation and on the discharge paperwork she was alert, oriented times three and 
denied any pain. 
 
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 ambulance services have not been met. Therefore, we decided that the Plan 
does not have to pay for ambulance services (A0428) provided on September 16, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray rendered on June 6, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that a SNF must submit all Medicare claims for all services 
under Part A. 
 
We looked at the file and Medicare rules. The file shows that procedure code 71045 was billed while the 
enrollee was in a SNF. Payment is included in payment to the SNF. Therefore, we decided that the Plan does 
not have to pay for the chest x-ray rendered on June 6, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the 30 mg/mL Fasenra subcutaneous syringe. 
 
You asked the Plan to pre-approve the 30 mg/mL Fasenra subcutaneous syringe. You say that you would like 
reconsideration because this service is medically necessary. The Plan denied your request. The Plan says the 
member does not met step therapy exception criteria. 
 
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 the 30 mg/mL Fasenra subcutaneous 
syringe. Our reviewer says that step therapy required one high-dose inhaled steroids and a long activation beta 
agonist inhaler in combination with one other daily asthma medication be trialed first. Our physician reviewer 
found the documentation does not outline contraindications or reason this medication regimen was not 
considered. 
 
 
 
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 30 mg/mL Fasenra subcutaneous syringe have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the 30 mg/mL Fasenra subcutaneous syringe.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on January 15, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says payments 
are not made directly or indirectly for Medicare covered services furnished to a Medicare beneficiary by a 
physician or practitioner who has opted out of Medicare unless billed for urgent or emergent services.  
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
physician's services provided on January 15, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve the trabecular bypass stent implantation provided on June 10, 2020. 
 
You asked the Plan to pre-approve the procedure. The Plan denied your request. The Plan says that this is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that glaucoma surgical aqueous drainage devices are 
covered for the above 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 procedure. Our reviewer says that 
the requested procedure was medically reasonable and necessary in this case. Our physician reviewer found 
that the enrollee had visually significant cataract causing difficulty with activities, and open angle glaucoma. 
Medicare covers insertion of a single trabecular bypass implant at the time of cataract surgery for the purpose 
of glaucoma treatment.  There is no indication in the record that this case fell within the limitations of coverage 
as described in the LCD, and the health plan offers no specific argument for why criteria for coverage were not met. 
 
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 procedure have been met. Therefore, we decided that the Plan has to pre-
approve the trabecular bypass stent implantation provided on June 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fentanyl patches. 
 
You asked the Plan to pre-approve Fentanyl. You say that the enrollee has utilized other methods for pain 
management, and has been unable to get relief. The Plan denied your request. The Plan says Fentanyl to be 
taken at home is not covered under the Part B benefit. 
 
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 pre-approve Fentanyl patches.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transport chair, adult size, patient weight capacity up to 
and including 300 pounds (CPT Code E1038). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the information received did state the member had a pelvic fracture, but they are able to  
bear weight as tolerated. The Plan states it did not indicate that the member is unable to safely use a cane or 
walker to get around in their home. The Plan states the information they received did not include any 
information about a caregiver that would assist the member with a transport chair. 
 
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 DME. Our physician reviewer 
found the information received did state the member had a pelvic fracture, but they are able to bear weight as 
tolerated. The Plan states it did not indicate that the member is unable to safely use a cane or walker to get 
around in their home. The Plan states the information they received did not include any information about a 
caregiver that would assist the member with a transport chair. 
 
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve transport chair, adult size, patient weight capacity up to and including 300 pounds (CPT Code 
E1038).
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve therapeutic apheresis; with extracorporeal immunoadsorption, 
selective adsorption or selective filtration and plasma reinfusion (CPT Code 36516). 
 
You asked the Plan to pre-approve the service. You say that the member will be at a great risk of having a 
cardiac event should they stop treatment to include a heart attack, stroke or loss of life. The Plan denied your 
request. The Plan says that the service is not 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 service. Our physician reviewer 
found Aphoresis is an accepted therapy for this condition and the patient has been stable and has responded to 
therapy. Records support the diagnosis, therapy needs to be continued. 
 
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 service have been met. Therefore, we decided that the Plan has to pre-
approve therapeutic apheresis; with extracorporeal immunoadsorption, selective adsorption or selective 
filtration and plasma reinfusion (CPT Code 36516).  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an echocardiography provides on November 4, 2019. 
 
You asked the Plan to pay for the echocardiography. The Plan denied your request. The Plan says with limited 
exceptions you must use network providers to get your medical 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 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 
services at issue. 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 an echocardiography provided on November 4, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genetic testing. 
 
You asked the Plan to pre-approve the genetic testing. You say that you would like reconsideration because this 
testing is medically necessary. The Plan denied your request. The Plan says there is no documentation that the 
treating provider ordered this testing or that the member has any signs or symptoms or is prescribed any 
medications to indicate these tests would be medically necessary, or that the testing is being used to manage or 
treat a specific medical problem or 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 genetic testing. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided notes did not clearly show an expected treatment change which would 
be based on the genetic testing, nor would these tests likely produce an improved outcome based on the 
provided listed diagnoses. 
 
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 genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the genetic testing.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the C-reactive protein testing rendered on September 5, 
2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that C-reactive protein testing is covered when 
specific criteria are met. 
 
We looked at the file and Medicare rules. There is no documentation to support that the testing meets the 
Medicare criteria for coverage. 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 pay for the C-reactive protein 
testing rendered on September 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the contact lenses purchased June 22, 2020. 
 
You asked the Plan to pay for the contact lenses. You say that you would like this claim reprocessed and 
approved for reimbursement. The Plan denied your request. The Plan says the claim was processed correctly as 
you exceeded the maximum allowance of the vision care allowance benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan provides $175 allowance every 12 months for eyeglasses, frames, lenses, or contact lenses.  
 
We looked at the file and the Plan's rules. You last received eyeglasses in December 2019 and applied $125 to 
the allowance. When you received services in June 2020 you still had $50 remaining on the original $175 
because 12 months had not passed. Therefore, $50 was applied to your allowance and you exceeded the 
 
 
maximum benefit. Based on this information, we decided that the Plan's rules for coverage of the contact lenses 
have not been met. Therefore, we decided that the Plan does not have to pay for the contact lenses purchased 
June 22, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on December 17, 2019. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the place of service 
on the claim must reflect the location when the specimen was obtained. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
The claim provided shows the place of service as 81, an independent laboratory. The records do not indicate 
that an independent lab took the sample at issue. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for the lab services 
provided on December 17, 2019.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab services (CPT 87631) provided on March 18, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that this is not a 
covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 pay for the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee presented for an ED visit on March 18, 2020, for evaluation of nasal congestion and 
sore throat for one week. The enrollee had complaints of dry cough and URI. There was a specific clinical 
rationale for the obtained lab study. The review has determined that the requested testing was medically 
reasonable and 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 been met. The LCD referenced by the Plan is not applicable 
for the jurisdiction in question. Therefore, we decided that the Plan has to pay for the lab services (CPT 87631) 
provided on March 18, 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.