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

We decided that the Plan does not have to pre-approve a replacement partial. 
 
You asked the Plan to pre-approve the replacement partial. You say that your current partial hurts to wear. The 
Plan denied your request. The Plan says your current partial is less than 60 months old. 
 
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 replacement of removable and 
fixed prosthesis are limited to once every 60 months. The record shows that you received a maxillary partial 
denture on May 14, 2019, and your maxillary denture benefit has been exhausted. Therefore, we decided that 
the Plan does not have to pre-approve a replacement partial.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to approve additional payment for eyeglass frames. 
 
You asked the Plan to approve additional payment for eyeglass frames. You say that you would like the plan to 
reconsider coverage. The Plan denied your request. The Plan says that they have paid up to the benefit limit. 
 
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 covers up to $150.00 for eyeglasses or contact lenses every year. 
 
We looked at the file and the Plan's rules. The file shows that the plan has approved the maximum yearly 
benefit of $150. There is no provision in the contract which would require the plan to approve more than this 
amount. Therefore, we decided that the Plan does not have to approve additional payment for eyeglass frames.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve parathyroid planar imaging for the enrollee. 
 
You asked the Plan to pre-approve the imaging. You say that this is medically necessary. The Plan denied your 
request. The Plan says the criteria was not met. 
 
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 imaging. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the indications for parathyroid multi planar imaging include elevated serum calcium AND 
elevated parathormone levels. This enrollee's serum calcium is borderline elevated at 10.4 with upper limits for 
this lab at 10.3. More importantly the serum parathormone level for this patient is well within normal range at 
44 with normal 14-64. As such the clinician has not established the medical necessity for imaging. 
 
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 imaging have not been met. Therefore, we decided that the Plan does not 
have to pre-approve parathyroid planar imaging for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the observation care discharge (99217) provided on June 12, 
2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for observation care discharge. You say that the service was medically necessary. 
The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent service 
rendered by an out-of-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the observation care discharge (99217) provided 
on June 12, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on May 14, 2020. 
 
You asked the Plan to pay for the services provided. You say that the enrollee has potential health hazard 
related to developing other cardiomyopathy-related diseases. The Plan denied your request. The Plan says the 
service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that cardiovascular disease screening is only covered 
under certain medical indications.  
 
The records show that a comprehensive cardiomyopathy gene panel was provided. We looked at the file and 
Medicare rules. All cardiovascular risk assessment panels, except the basic lipid panel, are not covered for 
symptomatic patients with suspected or documented CV disease. 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 May 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the hub cap with a reflector, rim accent color, phone 
holder and USB charger (K0801). 
 
You asked the Plan to pre-approve the accessories. You say that you would like reconsideration because your 
power wheelchair is in poor condition and the manual wheelchair is not feasible for you to operate. The Plan 
denied your request. The Plan says these accessories are not medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the hub cap with a reflector, rim accent color, phone holder 
and USB charger (K0801).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on April 29, 2020 by a non-
contracted provider. 
 
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 were rendered by a non-contracted provider without 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 medical services provided on April 29, 2020 
by a non-contracted provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the new patient home visit (99345) provided on August 14, 
2020, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the new patient home visit. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained 
by the facility or the provider; therefore, payment has been correctly denied. 
 
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 new patient home visit (99345) provided on 
August 14, 2020, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided by an opted out physician on May 
28, 2020. 
 
You asked the Plan to pay for office visit. You say that you are appealing based on medical necessity. The Plan 
denied your request. The Plan says the denial of payment for this service is correct, because this provider has 
opted out of Medicare and is not payable. 
 
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 an office 
visit provided by an opted out physician on May 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endovenous ablation therapy (36482). 
 
You asked the Plan to pre-approve endovenous ablation therapy. You say that this is medically necessary. The 
Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that endovenous ablation therapy is covered if the 
patient remains symptomatic after a six-week trial of conservative therapy. The conservative therapy must be 
documented in the medical record. 
 
We looked at the file and Medicare rules. The submitted medical records do not include documentation of 
conservative therapy. Based on this information, we decided that Medicare rules for coverage of endovenous 
ablation therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve 
endovenous ablation therapy (36482).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the referral for an out-of-network provider. You say that you would like 
reconsideration because this service is medically necessary. The Plan denied your request. The Plan says it is 
not medically necessary for you to go to an out-of-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the medical services to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Taltz Auto Injector. 
 
You asked the Plan to pre-approve a Taltz Auto Injector. You say that this medication has worked for this 
enrollee. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the 
enrollee's Part D drug Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve a Taltz Auto Injector.  
 
Benefits for a Taltz Auto Injector may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the electrical osteogenesis stimulator (E0748). 
 
You asked the Plan to pre-approve the electrical osteogenesis stimulator. You say that you would like 
reconsideration because this apparatus is needed so that your bones can regrow and attach themselves to the rod 
and screws. The Plan denied your request. The Plan says medical necessity has not been established. 
 
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 electrical osteogenesis stimulator. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found there is no evidence of failed spinal fusion or that a minimum of 9 
months had elapsed since surgery. There is no evidence of multilevel spinal fusion. There is no evidence of 
previous failed spinal fusion at the same site. There are no other relevant active risk factors for failure of fusion 
that would support a relative exception to Medicare criteria. 
 
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 electrical osteogenesis stimulator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the electrical osteogenesis stimulator (E0748).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient post-stabilization hospital care provided on July 
4, 2020 to July 5, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the inpatient hospital care. You say that the hospital provided inpatient care, 
which was medically necessary and appropriate for the entire stay. The Plan denied your request. The Plan says 
enrollee's must receive their medical services from an in-network provider with the exception being urgent or 
emergent services. Non-emergent services with non-contracted providers require prior authorization before 
services being rendered. 
 
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 inpatient post-stabilization hospital care 
provided on July 4, 2020 to July 5, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug tests (88307, G8482) provided on January 31, 2020. 
 
You asked the Plan to pay for drug tests. You say that these tests were medically necessary. The Plan denied 
your request. The Plan says these tests were billed with an incorrect Place of Service code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules also say that the use of POS codes from the National POS code set, currently maintained by CMS, is 
required. 
 
We find that CPT code [Enter billing code at issue (e.g. 43856, K0002, etc.)] is not supported in the medical 
record. Specifically, these services were billed with POS code 81 for an independent laboratory. However, the 
record shows that the specimens were collected in an office setting, not in an independent laboratory. Based on 
this information, we decided that Medicare rules for coverage of drug tests have not been met. Therefore, we 
decided that the Plan does not have to pay for drug tests (88307, G8482) provided on January 31, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided May 11, 2020 to May 15, 
2020. 
 
You asked the Plan to pay for the inpatient hospital care. You say that DRG 480 was more appropriate for this 
claim. The Plan denied your request. The Plan says the correct DRG was paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG.  
 
In this case, you billed the services provided May 11, 2020 to May 15, 2020 with DRG 480. 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 inpatient hospital care. Our reviewer says that the record 
supports the assignment of DRG 481. Our physician reviewer found there was no clinical evidence to support 
billing of diagnosis code N17.0 in the original medical record or additional documentation submitted with 
dispute. DRG 481 has been appropriately assigned  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate DRG 480. Therefore, we decided that the Plan does not have to pay for 
inpatient hospital care provided May 11, 2020 to May 15, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. There are identifiable skilled therapy service needs. The beneficiary does not require skilled 
nursing or therapy services on a daily basis. This beneficiary does not meet severity of illness or intensity of 
service criteria for an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endodontic therapy (D3320) provided on July 15, 2020. 
 
You asked the Plan to pay for the endodontic therapy. The Plan denied your request. The Plan says this service 
is not a covered benefit under your dental plan. 
 
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 pay for the 
endodontic therapy (D3320) provided on July 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four gingival irrigations (D4921 x4) and three localized 
deliveries of antimicrobial agents (D4381 x3). 
 
You asked the Plan to pre-approve gingival irrigations and localized deliveries of antimicrobial agents. You say 
that you have gingival pain and bleeding. The Plan denied your request. The Plan says these services are not 
covered under your plan. 
 
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 four 
gingival irrigations (D4921 x4) and three localized deliveries of antimicrobial agents (D4381 x3).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the upper 
extremity. 
 
You asked the Plan to pre-approve MRI. You say that you have been given treatments in the past which were 
not efficacious. The Plan denied your request. The Plan says the denial of authorization for this service is 
correct, because you have not completed an appropriate course of physical therapy or home exercise program. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 pre-approve MRI. Our reviewer says that you do not 
meet the Medicare criteria for the requested MRI. Our physician reviewer found there is no documentation 
indicating that you have completed an appropriate course of physical therapy or home exercise program. 
Advancing to MRI imaging is not considered medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MRI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Magnetic Resonance Imaging (MRI) of the upper extremity.