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

We decided that the Plan does not have to pay for nurse practitioner services provided on June 30, 2020. 
 
You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require 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 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 nurse practitioner services provided on June 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the automatic external defibrillator (K0606) provided on 
May 12, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for automatic external defibrillator. You say that you were unaware prior 
authorization was required. 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 automatic external defibrillator (K0606) 
provided on May 12, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) 
provided to the enrollee on May 18, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not indicate services are necessary for treatment of the 
enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
 
 
 
 
 
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a knee orthosis with 
suspension sleeve (L1833, L2397) provided to the enrollee on May 18, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency room visit on June 27, 2020 and 
June 28, 2020. 
 
You asked the Plan to waive the copayment for emergency room visit. You say that you should only be 
charged for one night. The Plan denied your request. The Plan says you had gone to the emergency room on 
back to back days and the claims in question were processed 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 
copayment of $90 per visit for emergency care.  
 
You have been asked to pay copayment of $90 per visit for emergency room visit. This service falls within the 
emergency care 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 emergency room visit on 
June 27, 2020 and June 28, 2020.  
 
The Qualified Independent Contractor (QIC) read your letter and knows that you may have a quality of care concern. The QIC cannot address quality of care issues. We are forwarding your quality of care concern to the 
appropriate Quality Improvement Organization for further review. 
 
Your complaint about the doctor potentially not treating you in full is not a valid appeal for medical coverage. 
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to 
make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a balance board. 
 
You asked the Plan to pre-approve a balance board. You say that a balance board would help you reach your 
goal of being able to walk again. The Plan denied your request. The Plan says that this is not covered. 
 
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 a balance board.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a 
participating provider on November 21, 2019. 
 
You asked the Plan to waive the copayment for dermatology services. You say that you do not feel like they 
should have billed you in 2020. 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 $40 
copayment for physician/practitioner services/specialist.  
 
You have been asked to pay a $40 copayment for dermatology services. Dermatology services fall within the 
physician/practitioner services/specialist 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 a specialist office visit provided by a participating provider on November 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a refraction (92015) provided on June 24, 2020. 
 
You asked the Plan to pay for a refraction. You say that this was medically necessary. The Plan denied your 
request. The Plan says this was not provided by a routine vision network provider. 
 
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 eye refractions during a routine exam performed by an EyeQuest Routine Vision 
Care Provider. 
 
We looked at the file and the Plan's rules. The refraction at issue was not provided by an EyeQuest Routine 
Vision Care Provider. Based on this information, we decided that the Plan's rules for coverage of a refraction 
have not been met. Therefore, we decided that the Plan does not have to pay for a refraction (92015) provided 
on June 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99202) provided on June 26, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that the services rendered 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 office visit (99202) provided on June 26, 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 inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that you can safely receive the services you need in other settings. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for hip fracture after a fall. Your 
medical problems are stable. There are no identified problems that need inpatient medical management. There 
are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including 
either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The medical 
record supports a need for physical and occupational therapy but it does not support a need for an intensive 
rehabilitation therapy program. There is not a reasonable expectation that you will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer 
found that your condition does not meet Medicare criteria for IRF care. 
 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the guided tissue regeneration and bone replacement graft 
provided on June 11, 2020. 
 
You asked the Plan to pay for the guided tissue regeneration and bone replacement graft. You say that there is 
no in-network periodontist within 50 miles of your home. You say that some should be covered. The Plan 
denied your request. The Plan says the services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
guided tissue regeneration and bone replacement graft provided on June 11, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ztlido pad 1.8% for the enrollee. 
 
You asked the Plan to pre-approve the pad. You say that this is medically necessary. The Plan denied your 
request. The Plan says this medication does not fall under Part B. 
 
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 Ztlido pad 1.8% for the 
enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider for chiropractic 
services. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says physician's services must be provided by network providers. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the 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 
a referral to an out-of-network provider for chiropractic services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (00320) provided May 22, 2020. 
 
You asked the Plan to pay for anesthesia services. You say that please reprocess this claim totaling $1320.00 
and allow for reimbursement. The Plan denied your request. The Plan says the records do not support the billed 
service. There is insufficient documentation to corroborate the services and confirm Medicare coverage has 
been met. 
 
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 00320 QK (83 units) is anesthesia for all procedures on 
esophagus, thyroid, larynx, trachea and lymphatic system of neck. 
 
We find that CPT code 00320 QK (83 units) is not supported in the medical record. Specifically, the records do 
not include a clear, legible anesthesia report to support the billed units and service. The plan had made multiple 
attempts to obtain the needed records without success. Based on this information, we decided that Medicare 
rules for coverage of anesthesia services have not been met. Therefore, we decided that the Plan does not have 
to pay for anesthesia services (00320) provided May 22, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood bank physician services provided. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the code was 
not billed in accordance with Medicare policy. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 86077 is 1. You billed 2 units of this code, exceeding the MUE. Based on 
this information, we decided that Medicare rules for coverage of the services provided have not been met. 
Therefore, we decided that the Plan does not have to further pay for the blood bank physician services provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for incontinence supplies, incontinence pads (A4590). 
 
You asked the Plan to pay for incontinence supplies. You say that you had talked to a plan representative and 
she said that these charges would be paid for. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pay for incontinence supplies, incontinence 
pads (A4590).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intracept procedure (CPT Code 22899 and C9752). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the services are not 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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Intracept procedure remains experimental. More research is needed to show safety and 
efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve intracept procedure (CPT Code 22899 and C9752).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary interim partial denture (D5820). 
 
You asked the Plan to pre-approve the maxillary interim partial denture. You say that you were told that 
dentures were covered. The Plan denied your request. The Plan says this service is not covered under your 
benefit 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 a 
maxillary interim partial denture (D5820).  
 
Your complaint about being misinformed is not a valid appeal for medical coverage. This part of your 
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision 
about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) for tooth # 5. 
 
You asked the Plan to pre-approve the dental service. You say that your crown is loose. The Plan denied your 
request. The Plan says the crown is not listed as a covered service. 
 
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 
crown (D2740) for tooth # 5.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ajovy 225mg/1.5ml autoinjector for the enrollee. 
 
You asked the Plan to pre-approve the drugs. You say that this is medically necessary. The Plan denied your 
request. The Plan says drug coverage is limited to Medicare Part B covered drugs. 
 
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 Ajovy 225mg/1.5ml 
autoinjector for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zioptan drops 0.0015% for the enrollee. 
 
You asked the Plan to pre-approve the drops. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested medication is denied as a benefit exclusion. 
 
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 Zioptan drops 0.0015% for 
the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an extraction (D7210) for tooth # 7 and a partial upper 
denture (D5211). 
 
You asked the Plan to pre-approve the dental services. The Plan denied your request. The Plan says the 
provider in this case is not a network provider. The Plan says that dental services that you receive out of 
network are not covered. The Plan also says there are in network dentists that are available to provide these 
services. 
 
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 and extractions and partial dentures are 
listed as covered services, dental services that you receive out of network are not covered. Therefore, we 
decided that the Plan does not have to pre-approve an extraction (D7210) for tooth # 7 and a partial upper 
denture (D5211).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core buildup, including any pins when required 
(D2950). 
 
You asked the Plan to pre-approve the core buildup. You say that your dentist said a lot of your tooth is broken 
off, and you need to have a core buildup prior to getting a crown. The Plan denied your request. The Plan says 
this service is not a covered benefit 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 a 
core buildup, including any pins when required (D2950).