Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hernia repair surgery to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a hernia repair surgery. You say that you need to have this done to feel your 
best. The Plan denied your request. The Plan says there are many other in-network providers within the same 
mileage of this out-of-network provider. Therefore, the decision is upheld. 
 
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 hernia repair surgery to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a facility visit provided on November 24, 2022. 
 
You asked the Plan to pay for a facility visit. You say that this was medically necessary and should be covered. 
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 a facility visit provided 
on November 24, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for procedure code J3490 billed for date of service November 28, 2022. 
 
You asked the Plan to pay for the billed services. You say that the drug was a medically necessary part of the 
enrollee's treatment. The Plan denied your request. The Plan says that the code is included in the global surgery 
period for code 27096. 
 
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 J3490 is unclassified drugs. We find that CPT code J3490 
is supported in the medical record. Code J3490 was submitted with a national drug code that coincides with the 
drug documented in the medical records. Code J3490 is not an evaluation and management service. Code 
J3490 is separately payable in this case. The Plan has not provided a Medicare rule that would indicate the drug 
should be included in the global surgery package. Based on this information, we decided that Medicare rules 
for coverage of the billed services have been met. Therefore, we decided that the Plan has to pay for procedure 
code J3490 billed for date of service November 28, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-rays provided on April 06, 2022. 
 
You asked the Plan to pay for the chest x-rays. You say that the claim was not paid under the terms of the 
contract. 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 the chest x-rays 
provided on April 06, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network emergency room (ER) 
observation provided on December 11, 2021, to December 14, 2021. 
 
You asked the Plan to waive the copayment for an in-network emergency room (ER) observation. You say that 
you feel you should not owe this much of a copayment. You thought this would be covered in full. 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 $295 
copayment for outpatient hospital observation services. 
 
You have been asked to pay a $295 copayment for an in-network emergency room (ER) observation. This 
item/service falls within the outpatient hospital observation 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 in-network emergency room (ER) observation provided on December 11, 2021, 
to December 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the application of fluoride (D1206) and the periodontal 
maintenance (D4910) provided on October 5, 2022. 
 
You asked the Plan to pay for the dental services. You say that the dental services were coded wrong, and they 
are covered under your dental plan. The Plan denied your request. The Plan says the denial of payment for 
these services is correct, because the application of fluoride and the periodontal maintenance 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 pay for the 
application of fluoride (D1206) and the periodontal maintenance (D4910) provided on October 5, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the mental health care visits provided from 
October 20, 2022, to November 1, 2022. 
 
You asked the Plan to waive the copayments for the mental health care visits. You say that you are unhappy 
with the services you received. 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 $40 
copayment for each in-network individual/group therapy session.  
 
You have been asked to pay a $40 copayment for each mental health care visit. These items/services fall within 
the outpatient mental health 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 copayments for 
the mental health care visits provided from October 20, 2022, to November 1, 2022.  
 Your complaint about the services not helping you 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient level of care for the approved surgery. 
 
You asked the Plan to pre-approve an inpatient level of care for the approved surgery. You say that the 
requested inpatient level of care for the approved surgery is medically necessary. The Plan denied your request. 
The Plan says the requested inpatient level of care for the approved surgery 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 an inpatient level of care for the 
approved surgery. Our reviewer says that the requested inpatient level of care for the approved surgery is not 
medically necessary. Our physician reviewer found the record indicates that the enrollee is scheduled for right 
total shoulder arthroplasty. The record provided does not indicate that the medical condition, safety, or health 
of the enrollee would be significantly and directly threatened if care was provided in a less intensive setting. 
The initial day may be spent in observation until it is clearly expected that an inpatient stay would be required, 
at which time the physician may order inpatient admission. The elements of the coverage criteria are not 
satisfied. The requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an inpatient level of care for the approved surgery have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an inpatient level of care for the approved 
surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a post removal and incomplete endodontic therapy services 
(D3332, D2955) provided on October 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental 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. 
 
 
  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 post 
removal and incomplete endodontic therapy services (D3332, D2955) provided on October 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient level of care for the approved surgery.

You asked the Plan to pre-approve an inpatient level of care for the approved surgery. You say that the requested inpatient level of care for the approved surgery is medically necessary. The Plan denied your request. The Plan says the requested inpatient level of care for the approved surgery 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 an inpatient level of care for the approved surgery. Our reviewer says that the requested inpatient level of care for the approved surgery is not medically necessary. Our physician reviewer found the record indicates that the enrollee is scheduled for right total shoulder arthroplasty. The record provided does not indicate that the medical condition, safety, or health of the enrollee would be significantly and directly threatened if care was provided in a less intensive setting. The initial day may be spent in observation until it is clearly expected that an inpatient stay would be required, at which time the physician may order inpatient admission. The elements of the coverage criteria are not satisfied. The requested service is not recommended.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an inpatient level of care for the approved surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient level of care for the approved surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care provided on August 11, 2022. 
 
You asked the Plan to pay for wound care. 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 wound care provided on 
August 11, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gemtesa (J8499). 
 
You asked the Plan to pre-approve Gemtesa. You say that the enrollee has tried alternatives, but they do not 
work well. The Plan denied your request. The Plan says Gemtesa is a self-administered drug. The Plan also 
says this drug is not covered for the enrollee's condition by Medicare 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 Gemtesa (J8499).  
 
  Benefits for Gemtesa 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport provided on October 7, 2022. 
 
You asked the Plan to pay for the ambulance service, basic life support, non-emergency transport. You say that 
you fell and could not get up. You also say that you weren't aware of the non-coverage for the ambulance 
coming to your home and if you weren't transported to the hospital. The Plan denied your request. The Plan 
says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on October 7, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance service, basic life support, non-
emergency transport provided on October 7, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on January 08, 2021, to October 
25, 2021. 
 
You asked the Plan to pay for physical therapy. 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 physical therapy 
provided on January 08, 2021, to October 25, 2021.
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 you are bedridden and require rehabilitation to regain 
strength, endurance and return home independently. The Plan denied your request. The Plan says the services 
you need can be provided safely in another setting such as, a skilled nursing facility, home with home health 
services or home with outpatient therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
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 you do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99051 billed for date of service November 
13, 2022. 
 
You asked the Plan to pay for procedure code 99051. You say that the claim must be paid in full. The Plan 
denied your request. The Plan says procedure code 99051 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 99051 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99051 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
99051 billed for date of service November 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an external upper limb tremor stimulator of the 
peripheral nerves of the wrist (K1018) and replacement supplies and accessories for external upper limb tremor 
stimulator of the peripheral nerves of the wrist (K1019). 
 
You asked the Plan to pre-approve an external upper limb tremor stimulator and replacement supplies and 
accessories for external upper limb tremor stimulator. You say that you disagree with the Plan's determination 
for both the Cala Trio and supplies. The Plan denied your request. The Plan says the device is considered 
experimental investigational and cannot be approved. The Plan also says the device has not been shown to be a 
safe or helpful treatment for your condition. 
 
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 an external upper limb tremor 
stimulator and replacement supplies and accessories for external upper limb tremor stimulator. Our physician 
reviewer found based on the medical records provided there is no documentation that the Cala Trio device at 
issue in this case meets all Medicare criteria for medically reasonable and necessary and safe and effective for 
you. Our reviewer also found that the provided records do not fully clarify that all medications (for example, 
prednisone, which is listed as a one of your current medications) or other substances such as caffeine that could 
be exacerbating the tremor have been discontinued. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an external upper limb tremor stimulator and replacement supplies and 
accessories for external upper limb tremor stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an external upper limb tremor stimulator of the peripheral nerves of the wrist 
(K1018) and replacement supplies and accessories for external upper limb tremor stimulator of the peripheral 
nerves of the wrist (K1019).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a K3 knee and K3 foot. 
 
You asked the Plan to pre-approve a K3 knee and K3 foot. You say that the requested K3 knee and K3 foot are 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
requested K3 knee and K3 foot. 
 
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 a K3 knee and K3 foot. Our reviewer 
says that the enrollee does not meet criteria for the requested K3 knee and K3 foot. Our physician reviewer 
found the documentation does not support that the enrollee is a K3 ambulator. The enrollee's ambulatory aides 
include a wheelchair, walker, and 2 Lofstrand crutches. The requested items in this case exceed the enrollee's 
functional needs. 
 
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 K3 knee and K3 foot have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a K3 knee and K3 foot.