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

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit (99327) and initial new 
patient preventive medicine evaluation (99387) provided on February 7, 2020, by an out of network (OON) 
provider. 
 
You asked the Plan to pay for domiciliary or rest home visit and initial new patient preventive medicine 
evaluation. You say that the services were medically necessary. The Plan denied your request. The Plan says 
prior authorization must be obtained for non-emergent services 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 domiciliary or rest home visit (99327) and 
initial new patient preventive medicine evaluation (99387) provided on February 7, 2020, by an out of network 
(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the comprehensive eye exam (92014) to be provided by 
an out of network provider. 
 
You asked the Plan to pre-approve the vision services. You say that you need to continue seeing this provider 
because she knows what is going on and you do not understand why you are being denied for an in network 
provider. The Plan denied your request. The Plan says enrollee's must receive vision services from an in 
network provider. The plan has confirmed that there are in network providers that are available to provide the 
requested services. 
 
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 these services when the services are rendered by an in-network provider. 

We looked at the file and the Plan's rules. Enrollee's must go to an in-network provider for covered vision 
services. Based on this information, we decided that the Plan's rules for coverage of the vision services have 
not been met. Therefore, we decided that the Plan does not have to pre-approve the comprehensive eye exam 
(92014) to be provided by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the established patient office or other outpatient visit and 
routine electrocardiogram (99214, 93000) provided on April 9, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the established patient office or other outpatient visit and routine EKG. You say 
that the office visit was part of the continuity of care and was medically necessary. 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 established patient office or other outpatient 
visit and routine electrocardiogram (99214, 93000) provided on April 9, 2020 by an out of network (OON) 
provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is in an acute care setting where he is not 
being provided with physical therapy to help heal his injuries. You also say that the longer the enrollee sits 
around waiting idle, the more likely he will lose muscle mass and be unable to rebound back to full capacity. 
The Plan denied your request. The Plan says the IRF services do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there is no evidence of medical issues that require monitoring by an inpatient rehab 
physician three times a week. Our reviewer found that the documentation does not support that there is a need 
for an intensive therapy program at the current functional level with 3 hours a day and an interdisciplinary 
approach to rehab care. Our physician reviewer also found that the enrollee's rehab needs can be met in an 
alternate, less intense 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids provided on May 28, 2020. 
 
You asked the Plan to pay for the hearing aids. You say that the information about changes in the benefits was 
not conveyed to you timely and clearly, so you believe the claim for the hearing aids should be paid. The Plan 
denied your request. The Plan says the hearing benefit is not covered if the hearing aids are not ordered through 
the designated vendor. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for 
hearing aids only when ordered from the Plan's designated vendor.  
 
We looked at the file and the Plan's rules. The file shows the hearing aids were not provided from the Plan's 
designated vendor. Based on this information, we decided that the Plan's rules for coverage of the hearing aids 
have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids provided on May 
28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pain management services (CPT 64636 and CPT 99153) 
provided to the enrollee on February 11, 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 the denied codes are not supported by the medical records submitted. 
 
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 code: 
 
CPT 64636: 
 
Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); 
lumbar or sacral, each additional facet joint 
 
CPT 99153: 
 
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 
 
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 
operative report documents Destruction by neurolytic agent, at L4, L5 and S1, which would be result of 2 facet 
joints.  Operative report does not include the resence of an independent trained observer to assist in the 
 
 
monitoring of the enrollee's level of consciousness and physiological status.  Therefore, these codes cannot be 
verified. 
 
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 pain management services (CPT 64636 and CPT 99153) provided to the enrollee on February 
11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you would like reconsideration because the 
special shoes are necessary for your condition. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM) 
(K0554, K0553). 
 
You asked the Plan to pre-approve a Dexcom G6 CGM. You say that this should be covered. 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 CGM devices are covered when the beneficiary 
is insulin-treated with multiple (three or more) daily injections of insulin or a Medicare-covered continuous 
subcutaneous insulin infusion (CSII) pump.  
 
We looked at the file and Medicare rules. The records do not show that you are treated with three or more daily 
injections of insulin. Based on this information, we decided that Medicare rules for coverage of a Dexcom G6 
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 
continuous glucose monitor (CGM) (K0554, K0553).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a post-operative re-evaluation (D0171), a cone beam CT 
capture (D0367), guided tissue regeneration (D4267), an implant (D6010), second stage implant surgery 
(D6011), a custom fabricated abutment (D6057), an abutment supported crown (D6058), a radiographic or 
surgical implant index (D6190), and a bone replacement graft for ridge preservation (D7953). 
 
You asked the Plan to pre-approve the dental services. You say that you do not have molars left on the upper 
left side. You say that you need these services so that you have an anchor for a bridge. The Plan denied your 
request. The Plan says the dental services you received are not listed. The Plan also says that any services not 
specifically listed are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
post-operative re-evaluation (D0171), a cone beam CT capture (D0367), guided tissue regeneration (D4267), 
an implant (D6010), second stage implant surgery (D6011), a custom fabricated abutment (D6057), an 
abutment supported crown (D6058), a radiographic or surgical implant index (D6190), and a bone replacement 
graft for ridge preservation (D7953).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve these OON services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services can be provided by a 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 
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 Pantoprazole Tab. 
 
You asked the Plan to pre-approve Pantoprazole Tab. You say that you want the enrollee treated with this drug. 
The Plan denied your request. The Plan says this drug is not covered under the enrollee's Part B Medicare 
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 Pantoprazole Tab.  
 
Benefits for Pantoprazole Tab 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns (D2740) for teeth # 7 and 9, core build up 
(D2950) for teeth # 7 and 9, and periodontal maintenance (D4910).  
 
You asked the Plan to pre-approve the crowns for teeth # 7 and 9, core build up, and periodontal maintenance. 
You say that the requested services are medically necessary. The Plan denied your request. The Plan says the 
root canals for teeth # 7 and 9 have not been completed and therefore the crowns and core build up are not 
medically necessary. The Plan says that the provided documentation was not labeled. The Plan also says the 
periodontal maintenance is not medically necessary. 
 
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 Plan covers the crowns, 
core build up, and periodontal maintenance when the services are medically necessary and reasonable.  
 
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 crowns, core build up, and 
periodontal maintenance. Our reviewer says that the requested dental services are not medically necessary. Our 
 
 
physician reviewer found the provided documentation shows there to be periapical pathology associated with 
teeth # 7 and 9. The reviewer found that this must be treated prior to the core build up and crown placement. 
The reviewer also found that the periodontal maintenance are not considered medically reasonable and 
necessary until the results of the outcome of the periodontal scaling and root planing are known. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crowns, core build up, and periodontal maintenance have not been met. 
Therefore, we decided that the Plan does not have to pre-approve crowns (D2740) for teeth # 7 and 9, core 
build up (D2950) for teeth # 7 and 9, and periodontal maintenance (D4910).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for outpatient hospital observation provided 
on April 24, 2020, and May 29, 2020. 
 
You asked the Plan to waive the copayments for outpatient hospital observation. You say that you disagree 
with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are 
being charged the correct amount. 
 
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 $298 
copayment for outpatient hospital observation.  
 
You have been asked to pay the total allowed amount of $221.46, which is less than the total copayment 
amount for outpatient hospital observation. Outpatient hospital observation falls within the outpatient hospital 
observation 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 copayments for outpatient hospital 
observation provided on April 24, 2020, and May 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system. 
 
You asked the Plan to pre-approve a power seat elevation system. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) is non-
covered because they are not primarily medical in nature. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a power seat elevation system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power seat elevation system.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic mammogram you had at an 
outpatient hospital facility on June 18, 2020. 
 
You asked the Plan to waive the copayment for the diagnostic mammogram. You say that you had your annual 
screening mammogram in December of 2019.  You say that your doctor saw a spot on your right breast and 
advised you to have another mammogram in six months.  You say that because the diagnostic mammogram 
you had in June of 2020 was a necessary follow-up, you should not have to pay the copayment. The Plan 
denied your request. The Plan says you were charged this copayment correctly. 
 
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 $50 
copayment for x-ray services provided at an outpatient hospital facility.  
 
You have been asked to pay a $50 copayment for the diagnostic mammogram. The diagnostic mammogram 
falls within the x-ray services provided at an outpatient hospital facility benefit category. This copayment 
applies even to medically necessary follow-up services. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
the diagnostic mammogram you had at an outpatient hospital facility on June 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for observation care service provided on June 8, 2019. 
 
You asked the Plan to pay for practitioner service. You say that you did not receive proper notice of the benefit 
determination. The Plan denied your request. The Plan says the denial of payment for this service is correct, 
because this claim was not submitted within the timely filing limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for practitioner service was not filed until July 17, 2020. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for observation care service provided on June 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton treatment. 
 
You asked the Plan to pre-approve the proton treatment. You say that the requested advanced technology could 
improve your quality of life. You say that you have a right to the requested treatment. You say that your cancer 
is aggressive and that every day counts. The Plan denied your request. The Plan says proton therapy 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 the proton treatment. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has high risk prostate cancer. Our physician reviewer found that the NCCN 
guidelines state that brachytherapy and EBRT are the only approved radiation treatment modalities in this case. 
 
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 proton treatment have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton treatment.