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

We decided that the Plan does not have to pre-approve a maxillary partial denture and mandibular partial 
denture. 
 
You asked the Plan to pre-approve the maxillary partial denture and mandibular partial denture. You say that 
you need the dentures because the one you have is metal, and you never use it because it does not fit well. The 
Plan denied your request. The Plan says these services exceed the benefit allowance. 
 
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, dentures are limited to one set every 
five years. The record shows that you received a maxillary partial denture and a mandibular partial denture on 
November 6, 2019, and your dentures benefit has been exhausted. Therefore, we decided that the Plan does not 
have to pre-approve a maxillary partial denture and mandibular partial denture.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and accessory 
(E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that this is medically necessary. 
The Plan denied your request. The Plan says you have not had a trial with a basic pump. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that you had at least four weeks 
of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and 
supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. 
Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and 
accessory (E0667).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI of the chest with contrast for the enrollee. 
 
You asked the Plan to pre-approve the MRI. You say that this is needed for further evaluation of the cause of 
the condition. The Plan denied your request. The Plan says this is not supported in the evaluation of non-
cardiac chest pain. 
 
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 the MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found a review of the records 
does not reveal a plan for MRI of the chest. Rather, the note of 10/10/20 indicates a plan for CT of the thorax 
with contrast. MRI of the chest would not be the procedure of choice. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve MRI of the chest with contrast for the enrollee.
Appeal type: Practitioner Services
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 out-of-network referral. You say that you would like reconsideration 
because there are not in-network providers who can render the requested procedure. The Plan denied your 
request. The Plan says there are in-network providers available who can render this service. 
 
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve specialist services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve specialist services. You say that you would like approval for these services. 
The Plan denied your request. The Plan says there are in-network providers available for these services. 
 
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 
specialist services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for telehealth services (HCPCS G2025) provided to the enrollee 
on March 25, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Medicare rule for payment of this claim was not met and could not be processed for payment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
In this case, the CPT Code Manual definition of HCPCS code G2025 is "Payment for a telehealth distant site 
service furnished by a rural health clinic (rhc) or federally qualified health center (fqhc) only."
 
We asked our coding 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 
services at issue in this case were not supported by the medical records. Our coding reviewer found the denied 
code was not submitted with Medicare required additional HCPCS codes, therefore, the rule/guideline for 
payment has not been met. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for telehealth services (HCPCS G2025) provided to the enrollee on March 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a backup transmitter for a continuous glucose monitor. 
 
You asked the Plan to pre-approve the transmitter. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the transmitter. Our reviewer says that 
the requested transmitter is not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no specific clinical rationale for the requested item. You the Plan to provide you with a 
back-up in case of failure of the transmitter in the middle of the night. The review has determined that the 
requested back-up transmitter at issue in this case is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the transmitter have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a backup transmitter for a continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services with CPT code S9328 
provided from March 31, 2020 to June 23, 2020. 
 
You asked the Plan to pay for CPT code S9328. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered. 
 
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 looked at the file and Medicare rules. In this case, CPT code S9328 has a status code of "I" under the 
Medicare Physicians Fee Schedule Database (MPFSDB) and is not valid for Medicare purposes. Medicare uses 
another code for reporting of, and payment for, this service. Therefore, we decided that the Plan does not have 
to pay for the home infusion therapy services with CPT code S9328 provided from March 31, 2020 to June 23, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for telehealth services provided by a 
participating provider on August 21, 2020. 
 
You asked the Plan to waive the copayment for telehealth services. You say that you didn't know there was a 
copayment for telehealth services. The Plan denied your request. The Plan says the correct copayment has been 
applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for physician/practitioner services/telehealth services/$30.  
 
You have been asked to pay a $30 copayment for telehealth services. Telehealth services fall within the 
physician/practitioner services/telehealth services/$30 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 telehealth services provided by a participating provider on August 21, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve individual psychotherapy session (90837) psychiatric 
diagnostic evaluation (90791) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the psychiatric services. You say that please reconsider as your symptoms 
are getting worse due to not being able to get proper treatment. 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 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 
individual psychotherapy session (90837) psychiatric diagnostic evaluation (90791) to be provided by an out-
of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care provided on May 27, 2020. 
 
You asked the Plan to pay for the subsequent hospital care (99232). You say that the Plan should pay this 
claim. The Plan denied your request. The Plan says Original Medicare is responsible for this claim. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on May 22, 2020. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care 
provided on May 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on August 24, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
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 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 services. Therefore, we decided that 
the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider 
on August 24, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chair car transportation. 
 
You asked the Plan to pre-approve the chair car transportation. You say that you would like reconsideration 
because the member cannot walk or get to the hospital without assistance. The Plan denied your request. The 
Plan says a wheelchair van is not covered by Medicare even if provided by an ambulance company. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
The services you have asked the Plan to pre-approve are wheelchair van transport services. Therefore, we 
decided that the Plan does not have to pre-approve chair car transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Precision Neo blood glucose test strips. 
 
You asked the Plan to pre-approve Freestyle Precision Neo blood glucose test strips. You say that this is 
medically necessary. The Plan denied your request. The Plan says this is not a preferred brand. 
 
The Plan must follow Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers 
as preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those 
preferred brands and manufacturers. The Plan contract says that diabetes test strips and monitors must be 
obtained from preferred vendors Accu-Chek and OneTouch. 
 
We looked at the file and Medicare rules. The requested test strips are not the Plan?s preferred brands and there 
is no reason stated in the submitted record why is it medically necessary for you to use a different brand. Based 
on this information, we decided that Medicare rules for coverage of Freestyle Precision Neo blood glucose test 
strips have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle Precision 
Neo blood glucose test strips.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 18 additional miles for routine transportation 
 
You asked the Plan to pre-approve the additional miles. You say that you are appealing the denial. You are 
legally blind and need transportation for appointments related to your eyes. The Plan denied your request. The 
Plan says this request exceeds the benefit limit of 50 miles. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan?s coverage rules apply in this 
case. The Plan covers a maximum of 48 one way trips per calendar year. Each one-way trip must not exceed 50 
miles trips per year. You are requesting to go to a provider that is 68 miles away. Therefore this request 
exceeds the benefit limitation. 
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve 18 additional miles for routine transportation
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you are unable to stand long periods of time. 
The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a skin graft for the enrollee. 
 
You asked the Plan to pre-approve the graft. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not medically necessary. 
 
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 pre-approve the graft. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found after first line therapies have failed, the skin graft is necessary to avoid surgery, such as amputation. 
 
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 graft have been met. Therefore, we decided that the Plan has to pre-approve 
a skin graft 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit services (CPT 93294 and CPT 93296) provided 
to the enrollee on June 16, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this procedure code is not correct for these services. 
 
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 the denied codes is: 
 
CPT 93294: 
 
Interrogation device evaluation(s) (remote), up to 90days; single, dual, or multiple lead pacemaker system, or 
leadless pacemaker system with interim analysis, review(s) and report(s) by a physician or other qualified 
health care professional 
 
CPT 93296: 
 
Interrogation device evaluation(s) (remote), up to 90 days; single, dual, or multiple lead pacemaker system, 
leadless pacemaker system, or implantable defibrillator system, remote data acquisition(s), receipt of 
transmissions and technician review, technical support and distribution of results 
 
We asked our coding 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 
services at issue in this case were not supported by the medical records. Our coding reviewer found that per the 
documentation, the services were reimbursed for the date of service 3/20/20. Per the AMA CPT guidelines 
"Codes 93293 - 93296 are reported no more than once every 90 days.  Do not report 93293 - 93296 if 
monitoring period is less than 30 days". The dates of service March 20, 2020 and June 16, 2020 are less than 30 
days. Therefore, the current date of service - June 16, 2020 - would not be reimbursable. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for office visit services (CPT 93294 and CPT 93296) provided to the enrollee on June 16, 2020.