Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the root canal (D3320), cone beam computed tomography 
(D0380), and a limited oral evaluation (D0140), provided on November 11, 2021. 
 
You asked the Plan to pay for the routine dental services. You say that the services should be covered. The Plan 
denied your request. The Plan says the services were received out of the Plan's network. 
 
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 root canal (D3320), cone beam computed tomography (D0380), and a limited oral evaluation (D0140), provided on 
November 11, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tecentriq for the enrollee. 
 
You asked the Plan to pre-approve Tecentriq. You say that this is medically necessary. The Plan denied your 
request. The Plan says that documentation does not support that the disease has not progressed while on or 
following anti-PD-1/PD-L1 therapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Tecentriq. Our reviewer says that 
Tecentriq is not medically reasonable and necessary. Tecentriq is not FDA-approved for the enrollees 
diagnosis as there was prior progression on pembrolizumab. The use of Tecentriq is not supported by one of the 
major drug compendia or by clinical research that appears in a CMS-approved medical journal. Our physician 
reviewer found that the enrollee's condition does not meet criteria for coverage of Tecentriq. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Tecentriq have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Tecentriq for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn. 
 
You asked the Plan to pre-approve Gelsyn. You say that the requested Gelsyn is medically necessary. The Plan 
denied your request. The Plan says the enrollee must try and fail Gel-One and Euflexxa first. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 Gelsyn. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found based on the medical records 
provided there is no indication that the enrollee has tried and failed the required drug(s). Based on the medical 
records provided there is no indication that the plan's required drug(s) would likely be less effective and/or 
likely have adverse effects for the enrollee. Also, provided records do not document that the enrollee has tried 
and failed physical therapy and joint aspiration and an intra-articular steroid injection. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gelsyn have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Gelsyn.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for medical services provided by a family medicine provider on November 
17, 2021. 
 
You asked the Plan to pay for the medical services. You say that this claim should not have been sent because 
these services were not received. The Plan denied your request. The Plan says that it has not received medical 
records from the provider to show that the services were rendered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
These services were billed by a contract provider. The file does not show that the Plan provided notice that the 
medical services would not be covered. Under Medicare rules, this means the medical services are considered 
approved by the Plan. Because the provider who billed these services is a contract provider with the Plan, it is 
the Plan's obligation to ensure that this provider is billing appropriately.  It is also the Plan's obligation to obtain 
records from their own contract providers.  The Plan's failure to do so should not result in a financial obligation 
for you. Therefore, we decided that the Plan has to pay for medical services provided by a family medicine 
provider on November 17, 2021.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel provided on August 31, 2021. 
 
You asked the Plan to pay for the gene panel. You say that the test is valuable when determining treatment for 
the enrollee. The Plan denied your request. The Plan says the request does not meet Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and the rules. The gene panel was billed with multiple codes. If a single procedure is 
performed, only one code with one unit of service may be reported for the procedure. The records also do not 
show that the enrollee has recurrent, relapsed, refractory, metastatic, or advanced cancer. Based on this 
information, we decided that Medicare rules for coverage of the gene panel have not been met. Therefore, we 
decided that the Plan does not have to pay for the gene panel provided on August 31, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Coflex device. 
 
You asked the Plan to pre-approve the Coflex device. You say that the requested Coflex device is medically 
necessary. The Plan denied your request. The Plan says the requested Coflex device 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.  
 The rules also say that experimental and investigational devices are not covered. The Coflex lumbar 
interspinous decompression device is unproven and not medically necessary due to insufficient evidence of 
efficacy. Therefore, we decided that the Plan does not have to pre-approve the Coflex device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid (V5261) and fitting (V5011), provided on 
November 1, 2021. 
 
You asked the Plan to pay for the hearing aid and fitting. You say that the services should be covered. The Plan 
denied your request. The Plan says the services were not received through a Plan provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only the hearing services are obtained through a Plan provider..  
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aid and fitting have not been met. Specifically, the services were not received through a 
Plan provider. Therefore, we decided that the Plan does not have to pay for the hearing aid (V5261) and fitting 
(V5011), provided on November 1, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for PT visits provided on January 11, 2022, 
January 17, 2022, and January 18, 2022. 
 
You asked the Plan to waive the copayment for PT visits. You say that although you enjoyed the therapy you 
don't believe it benefitted you. The Plan denied your request. The Plan says the copayment was applied 
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 $25 
copayment for physical therapy when in-network and received at a specialist's office or a comprehensive 
outpatient rehabilitation facility. 
 For dates of service January 17, 2022, and January 18, 2022, you have been asked to pay a $25 copayment for 
each visit. For date of service January 11, 2022, you have been asked to pay $3.59, which is less than the 
standard $25 copayment. Therefore, your total copayment responsibility is $53.59. PT visits falls within the 
Outpatient rehabilitation 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 
PT visits provided on January 11, 2022, January 17, 2022, and January 18, 2022.  
 
The issue with the overcharge/refund is out of our jurisdiction so you will have to contact the plan for more 
information about getting a refund for your overpayment.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on December 22, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services 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, the CPT Code Manual definition of code 55866 is "Laparoscopy, surgical prostatectomy, 
retropubic radical, including nerve sparing, includes robotic assistance, when performed." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the operative report supports CPT 
55866, but does not support adding the 22 modifier. The record does not show that the surgical procedure was 
exceptionally complicated as required for this modifier. Most surgeons use this modifier when the patient is 
morbidly obese, has extensive adhesions due to prior mesh placement or have an exceptionally large prostate 
gland (more than 50 cc). The records did not show that any of these difficulties were encountered. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services provided to the enrollee on 
December 22, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Emergency Room Services on January 25, 
2022. 
 
You asked the Plan to waive the copayment for Emergency Room Services. You say that you would like to 
appeal the cost share. The Plan denied your request. The Plan says the copayment applied is correct. 
 
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 $90 
copayment for Emergency Room Services.  
 
You have been asked to pay a $90 copayment for Emergency Room Services. Emergency Room Services 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 Services on January 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for durable medical equipment provided to the enrollee on 
August 19, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there is no documentation for the billed date of service. 
 The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. Medicare rules say that durable medical equipment (DME) supplies must be 
provided with a proof of delivery. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of durable medical equipment provided to 
the enrollee on August 19, 2021. have been met. The required documentation pertaining to the proof of 
delivery of these supplies on the billed date of service was not provided.. Therefore, we decided that the Plan 
does not have to pay for durable medical equipment provided to the enrollee on August 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) services 
 
You asked the Plan to pre-approve a CT scan. You say that  The Plan denied your request. The Plan says they 
need to know what problem the enrollee is having. The Plan says that they need to see medical records that say 
how the requested test will change the enrollee's treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of computed tomography (CT) services 
have been met. The Plan made reasonable attempts to obtain medical records. Therefore, we decided that the 
Plan does not have to pre-approve computed tomography (CT) services
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a "Smart Drive" wheelchair (push-rim power assist 
device). 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says a current evaluation is necessary to evaluate the enrollee for the appropriate 
mobility device. 
 
The Plan follows Medicare rules. Medicare rules say that a push rim power assist device will be covered if the 
basic coverage criteria for a power wheelchair are met, and the more specific criteria for the device is met. 
 
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 wheelchair. Our reviewer says that 
the requested device is not medically reasonable or necessary. Our physician reviewer found the documentation 
includes a physical therapy evaluation from 11/9/21, with no recent treating medical provider progress notes to 
evaluate your current medical condition. The documentation does not reveal an updated objective detailed 
neuromuscular and musculoskeletal exam. The strength is noted as "poor" without evidence of objective grades 
of strength measurements. There are no objective exam findings of a detailed manual muscle strength, degrees 
of range of motion, coordination deficits, of both upper extremities and lower extremities. The documentation 
is not clear that the home is appropriate for a wheelchair as there are no objective measurements of the home 
indicating that your home provides adequate access between rooms, maneuvering space, and surfaces for use of 
the manual wheelchair that is requested and that you can safely use the wheelchair in the home. Without 
evidence that the requested wheelchair will provide adequate space in the home it is not clear that the requested 
wheelchair will significantly improve participation in MRADLs in the home. 
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a "Smart Drive" wheelchair (push-rim power assist device).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office specialist visit provided on February 10, 2022 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for an office specialist visit. You say that you would like to request reconsideration 
of the denied claim. The Plan denied your request. The Plan says payment was not allowed because they did 
not receive a PCP referral to review and approve. They also determined that these services are not urgent or 
emergent. 
 
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 specialist visit provided on February 10, 
2022 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a spinal cord stimulator (SCS) trial. 
 
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 that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that electrical nerve stimulation is covered when 
specific criteria are met. 
 
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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee has chronic low back pain after 
three spine surgeries. She had a trial of physical therapy that did not hep. She has had epidural injections and 
radiofrequency ablation of the lumbar facet joints. She has a psychological clearance for the SCS trial. The 
criteria for coverage are met and the services are reasonable and 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 these services have been met. Therefore, we decided that the Plan has to pre-
approve a spinal cord stimulator (SCS) trial.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the walker and walker seat attachment that 
was provided by a network provider on July 22, 2021. 
 
You asked the Plan to waive the coinsurance for the walker and walker seat attachment. You say that you were 
told there would be no charge to you. The Plan denied your request. The Plan says you have been asked to pay 
the correct cost-sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% for 
Medicare-covered equipment and supplies.  
 
 
 You have been asked to pay $14.84 which is 20% of the allowed amount for the walker and walker seat 
attachment. The allowed amount is $74.21. ($74.21 x 20% = $14.84). The walker and walker seat attachment 
fall within Durable medical equipment (DME) and related 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 coinsurance for the walker and walker seat attachment that was provided by a 
network provider on July 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home ventilator (E0466) provided February 28, 2022 to 
May 27, 2022. 
 
You asked the Plan to pay for a ventilator. You say that the medical records provided support the necessity of 
the services in dispute. The Plan denied your request. The Plan says the requested items/services are not 
considered medically reasonable and necessary in this case. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 pay for a ventilator. Our reviewer says that  Our 
physician reviewer found a home ventilator is not medically necessary. This enrollee has oxygen-dependent 
COPD and was recently hospitalized with acute on chronic hypoxic and hypercarbic respiratory failure. The 
enrollee improved on BiPap. The enrollee may benefit from BiPap during sleep as an outpatient, with or without AVAPS. This has not been tried. Medicare does not pay for a ventilator when used as BiPap. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pay for a home ventilator (E0466) provided February 28, 2022 to May 27, 2022.