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

 
We decided that the Plan does not have to pre-approve Image Guided Radiation Therapy (IGRT). 
 
You asked the Plan to pre-approve IGRT. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IGRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found usually IGRT is used when critical structures are abutting or in close proximity to the target 
that is being treated to high doses. This situation does not apply to this enrollee for which the target lesion can 
be seen on the skin to assist in daily set up. When treating skin cancers, there is generally not a need for IGRT 
unless deep structures are being treated. To bill for IGRT (or daily simple simulations) for a technology for 
which need has not been established by published data or supported by consensus guidelines is not necessary. 
Billing for daily IGRT which would not be furnished in accordance with accepted standards of medical 
practice.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IGRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Image Guided Radiation Therapy (IGRT).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pulp cap (D3110) provided on October 13, 2022. 
 
You asked the Plan to pay for a pulp cap. You say that you needed this dental work. The Plan denied your 
request. The Plan says the rendered service has been correctly denied. 
 
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 pay for a pulp cap 
(D3110) provided on October 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft (D7953) provided on September 2, 
2022. 
 
You asked the Plan to pay for a bone replacement graft. You say that you believe this should be covered. The 
Plan denied your request. The Plan says this service has been correctly denied. 
 
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 pay for a bone 
replacement graft (D7953) provided on September 2, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Urolift (C9739, 52441, 52442, C9740). 
 
You asked the Plan to pre-approve a Urolift. You say that the service is medically necessary. The Plan denied 
your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that treatment for lower urinary tract symptoms 
(LUTS)/Benign prostatic hyperplasia (BPH) treatment will be considered reasonable and necessary when 
performed once in patients less than 80 years old,has a Prostate volume of 30-150 cc by transrectal ultrasound 
(TRUS), and Persistent moderate to severe symptoms despite maximal medical management. 
 
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 a Urolift. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the records do not show that the prostate 
volume is 30-150 cc by transrectal ultrasound. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Urolift have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a Urolift (C9739, 52441, 52442, C9740).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health provided on July 21, 2022. 
 
You asked the Plan to pay for outpatient mental health. You say that you are requesting reconsideration. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for outpatient mental health 
provided on July 21, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency bus transportation (A0110) and stretcher 
van mileage (T2049) provided on January 27, 2022. 
 
You asked the Plan to pay for the non-emergency bus transportation and stretcher van mileage. The Plan 
denied your request. The Plan says these services are not covered. 
 
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. 
The Plan follows the same rule.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Medicare rules for coverage of the non-emergency bus transportation and stretcher van mileage have 
not been met. Therefore, we decided that the Plan does not have to pay for the non-emergency bus 
transportation (A0110) and stretcher van mileage (T2049) provided on January 27, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network retroperitoneal ultrasound 
provided on September 1, 2022. 
 
You asked the Plan to waive the copayment for an in-network ultrasound. You say that the plan didn't pay 
anything, and you have a bill. 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 $165 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay the allowed amount of $112.02 which is less than the $165 copayment for an in-
network ultrasound. This item/service falls within the outpatient diagnostic tests and therapeutic services and 
supplies 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 an in-network retroperitoneal ultrasound 
provided on September 1, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 11, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services provided. 
The Plan denied your request. The Plan says there is no 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 11, 2022, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames, the trifocal lens, and the progressive lens 
provided on August 4, 2022. 
 You asked the Plan to pay for the frames, the trifocal lens, and the progressive lens. You say that you would 
like to be reimbursed for the glasses. You say you needed new glasses. The Plan denied your request. The Plan 
says the maximum benefit amount has been met. 
 
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 every two years. 
 
We looked at the file and the Plan's rules. Specifically, you received glasses two months prior to the vision 
benefit resetting its two-year eligibility period. Based on this information, we decided that the Plan's rules for 
coverage of the frames, the trifocal lens, and the progressive lens have not been met. Therefore, we decided 
that the Plan does not have to pay for the frames, the trifocal lens, and the progressive lens provided on August 
4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on August 31, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 02, 2022. 
Therefore, we decided that the Plan does not have to pay for the dental services on August 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an OON provider. 
 
You asked the Plan to pre-approve an office visit. You say that in-network providers had no appointments until 
May 2023. The Plan denied your request. The Plan says you must receive care from 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 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for a computed tomography (CT) scan (code 77014) provided on June 29, 
2022. 
 
You asked the Plan to pay for CT scan. You say that this service was medically warranted and billed 
appropriately. The Plan denied your request. The Plan says that this code is incidental to another service. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan denied this code on the basis that it is incidental to another service. 
However, the Plan has not submitted any evidence or specification of another code to which 77014 would be 
incidental. The Plan has not provided any other rationale to support a denial. Therefore, the Plan has not shown 
that its decision to deny payment for this code is correct or justified according to Medicare rules. Therefore, we 
decided that the Plan has to pay for a computed tomography (CT) scan (code 77014) provided on June 29, 
2022.  
 
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: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a crown on tooth #3 (D2740). 
 
You asked the Plan to pre-approve a crown. You say that the crown is medically necessary. The Plan denied 
your request. The Plan says that the supporting documentation was not received to show the medically 
necessity for the crown. 
 
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. The Plan covers a crown 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 a crown. Our reviewer says that that the 
coverage criteria has been met. Our physician reviewer found that the additional information indicates that 
tooth #3 has a three-surface restoration and a fractured mesio-buccal cusp. It is medically reasonable and 
necessary that a crown restoration be placed to preserve function and provide adequate strength. 
 
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 a crown have been met. Therefore, we decided that the Plan has to pre-approve 
a crown on tooth #3 (D2740).  
 
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 an office visit provided on July 5, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services provided. 
The Plan denied your request. The Plan says there is no 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 5, 2022, by an out-
of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient diagnostic tests provided on 
August 26, 2022. 
 
You asked the Plan to waive the copayment for an outpatient diagnostic test. You say that you disagree with 
the 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 $150 
copayment for outpatient diagnostic tests/Medicare-covered radiological diagnostic services.  
 
You have been asked to pay a $150 copayment for an outpatient diagnostic test. This item/service falls within 
the outpatient diagnostic tests/Medicare-covered radiological diagnostic services 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 an outpatient diagnostic tests provided on August 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a debridement procedure on the skin provided on September 
1, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a debridement procedure on the skin. You say that the services were medically 
necessary. The Plan denied your request. The Plan says there is no 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 debridement procedure on the skin provided on 
September 1, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 3D conformal radiation therapy and image-guided 
radiation therapy (IGRT). 
 
You asked the Plan to pre-approve 3D conformal radiation and IGRT. You say that the requested services are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
experimental/investigational. 
 
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 3D conformal radiation and IGRT. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that, for bone metastases in the setting of an extraosseous component. billing 
for 3D radiation is an accepted standard due to more complex treatment planning to not only cover the bone, 
but also the soft tissue component and the added complexity of sparing normal tissue when targeting bone plus 
soft tissues. In this case, there does not appear to be an extraosseous component. The treatment plan seems 
most consistent with what would be billed as 2D radiation. With regard to IGRT, for bone metastases it would 
generally not be standard to bill IGRT. For the palliative treatment of bone metastases, the use of IGRT is generally not considered medically necessary outside of a medically plausible rationale (i.e. prior radiation 
treatment, unusual anatomy). In this case, the intent is clearly palliative, and it is not clear what benefit IGRT 
would afford. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 3D conformal radiation and IGRT have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 3D conformal radiation therapy and IGRT.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 2, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the reports attached support the services provided. 
The Plan denied your request. The Plan says services can be obtained from an in-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 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 November 2, 2022, by 
an out-of-network (OON) provider.