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

We decided that the Plan does not have to pre-approve an office visit for a second opinion with an out-of-network specialist.

You asked the Plan to pre-approve the specialist visit. You say that you have a rare type of cancer. You say that you are seeing a second opinion at a larger facility to make sure your treatment plan is the best option for you. You say that the network provider you were recommended does not specialize in your type of cancer you have. You also say that it is important you have the best treatment for you to prevent complications. The Plan denied your request. The Plan says there are network providers that can provide a second opinion.

Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care.

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 specialist visit. Our reviewer says that the request for a second opinion with an out-of-network specialist is not medically necessary. Our physician reviewer found the provided documentation does not indicate there is anything unique about your condition that that would make it medically necessary for him/her to see the requested out-of-network provider. The reviewer found that the Plan has adequate network providers that provide the requested service. Therefore, the reviewer found that a second opinion with an out-of-network specialist is not medically 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 specialist visit have not been met. Therefore, we decided that the Plan does not have to pre-approve an office visit for a second opinion with an out-of-network specialist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine eyewear (V2025, V2100, V2750, V2784) 
provided on September 6, 2022, by an out-of-network (OON) provider. 
 You asked the Plan to pay for the routine eyewear. You say that you obtained glasses from the vendor who was 
in your eye doctor's office. The Plan denied your request. The Plan says routine eyewear is not covered when 
provided OON. 
 
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 obtained from a provider in the Plans vision vendors network. 
 
We looked at the file and the Plan's rules. In this case the routine eyewear was provided by an OON provider. 
Based on this information, we decided that the Plan's rules for coverage of the routine eyewear have not been 
met. Therefore, we decided that the Plan does not have to pay for the routine eyewear (V2025, V2100, V2750, 
V2784) provided on September 6, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services with an out-of-network provider. 
 
You asked the Plan to pre-approve the dental services. You say that the providers in your network are not as 
good. The Plan denied your request. The Plan says dental services from an out-of-network provider are not 
covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve dental 
services with an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 31, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the services provided were obtained to improve your 
health. The Plan denied your request. The Plan says there is no prior authorization on file for the services 
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 had network providers 
available who could have provided 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 an office visit provided on July 31, 2022, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation to be provided by an 
out-of-network provider. 
 
You asked the Plan to pre-approve the dental service. You say that the requested provider the enrollee has seen 
for years and would like to continue to get services from them. The Plan denied your request. The Plan says 
dental services from an out-of-network provider are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested item or service are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve a 
comprehensive oral evaluation to be provided by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 36000 and 94760 billed for date of service 
December 17, 2021. 
 
You asked the Plan to pay for procedure codes 36000 and 94760. You say that the services at issue have been 
billed correctly. The Plan denied your request. The Plan says procedure codes 36000 and 94760 are considered 
bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 36000 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 36000 is not separately payable. Procedure code 94760 has a status indicator of T on the 
Schedule. This means that procedure code 94760 is bundled into the physician services billed on the same date 
by the same provider for which payment is made. Based on this information, we decided that Medicare rules 
for coverage of procedure codes 36000 and 94760 have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure codes 36000 and 94760 billed for date of service December 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) device 
 
You asked the Plan to pre-approve a CGM. You say that a CGM help the enrollee. The Plan denied your 
request. The Plan says the criteria for a CGM have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a continuous glucose monitor (CGM) device
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S0395 billed for date of service July 12, 
2022. 
 
You asked the Plan to pay for procedure code S0395. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the billed code is invalid for Medicare 
purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure code S0395 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S0395 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S0395 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S0395 billed for date of service July 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic CGM and supplies. 
 
You asked the Plan to pre-approve a CGM and supplies. You say that the requested CGM and supplies are 
necessary for the enrollee to check their blood glucose levels. The Plan denied your request. The Plan says that 
the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections and does not require frequent self-adjustment of insulin dosage based on the 
blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a 
CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
therapeutic CGM and supplies.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 36000 and 94760 billed for date of service 
April 29, 2022. 
 
You asked the Plan to pay for procedure codes 36000 and 94760. You say that the services at issue have been 
billed correctly. The Plan denied your request. The Plan says procedure codes 36000 and 94760 are considered 
bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 36000 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 36000 is not separately payable. Procedure code 94760 has a status indicator of T on the 
Schedule. This means that procedure code 94760 is bundled into the physician services billed on the same date 
by the same provider for which payment is made. Based on this information, we decided that Medicare rules 
for coverage of procedure codes 36000 and 94760 have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure codes 36000 and 94760 billed for date of service April 29, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided from March 4, 2022, 
to March 11, 2022. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that the services should be covered 
because you were not aware you had a copayment. The Plan denied your request. The Plan says this cost 
sharing was charged 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 $20 
copayment per day for days 1 to 20 and $0 per day for days 21 to 100 for each SNF admission.  
 
You have been asked to pay a $140 copayment for a SNF stay ($20 per day x 7 days = $140). This item/service 
falls within the Skilled Nursing Facility 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 a SNF stay provided from March 4, 2022, to March 11, 2022.  Your complaint about not being aware of the required copayment 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a physical therapy services provided on March 2, 2022, to 
March 8, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a physical therapy service. You say that the records attached support the services 
provided. The Plan denied your request. The Plan says there is no prior authorization on file for the services 
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 had network providers 
available who could have provided 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 a physical therapy services provided on March 2, 
2022, to March 8, 2022, 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 on August 31, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the services provided were medically necessary to 
improve your health. The Plan denied your request. The Plan says there is no prior authorization on file for the 
services 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 had network providers 
available who could have provided 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 an office visit provided on August 31, 2022, by an 
out-of-network (OON) provider.
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 the services should be covered as you disagree 
with the denial. 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 the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot 
orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve osseous surgery (D4260), bone replacement grafts 
(D4263), and biologic materials (D4265) for tooth #2, #14, #18, and # 30 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the dental procedures 
that are not covered. The Plan denied your request. The Plan says the denial of authorization for these services 
is correct, because osseous surgery, bone replacement grafts, and biologic materials are not covered by the 
Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 
osseous surgery (D4260), bone replacement grafts (D4263), and biologic materials (D4265) for tooth #2, #14, 
#18, and # 30
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 36000 and 94760 billed for date of service 
January 5, 2022. 
 
You asked the Plan to pay for procedure codes 36000 and 94760. You say that the services at issue have been 
billed correctly. The Plan denied your request. The Plan says procedure codes 36000 and 94760 are considered 
bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 36000 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 36000 is not separately payable. Procedure code 94760 has a status indicator of T on the 
Schedule. This means that procedure code 94760 is bundled into the physician services billed on the same date 
by the same provider for which payment is made. Based on this information, we decided that Medicare rules 
for coverage of procedure codes 36000 and 94760 have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure codes 36000 and 94760 billed for date of service January 5, 2022.
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 a shower chair is medically necessary. The 
Plan denied your request. The Plan says this item is not covered by Medicare. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller, harness, electronic 
connection, power seat elevation system, and seat belt for a power wheelchair. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a lap/safety belt is included in the basic power 
wheelchair package. The rules say that an expandable controller is used to control multiple power options. The 
rules say that a power seat elevation system is not covered. 
 
We looked at the file and Medicare rules. The requested safety belt is not covered because it is already included 
int he approved wheelchair package. The file shows that the expandable harness is not needed to control the 
approved power switches. The power seat elevation system is not covered because it does not serve a purpose 
that is primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve an 
expandable controller, harness, electronic connection, power seat elevation system, and seat belt for a power 
wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99072 billed for date of service June 3, 2022. 
 
You asked the Plan to pay for procedure code 99072. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says procedure code 99072 is considered bundled and not 
separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99072 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99072 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99072 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99072 billed for date of service June 3, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 90833 provided on May 24, 2022. 
 
You asked the Plan to pay for procedure code 90833. 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 as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 90833 
is an add-on code and has not been billed with an appropriate primary procedure code. Based on the claim 
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 90833 provided on May 24, 2022.