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

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5211) provided by a 
participating provider. 
 
You asked the Plan to pre-approve the dental services. You say that you have a problem with the dental service. 
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 August 31, 2022. 
Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture (D5211) provided 
by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis (D1110) provided on July 23, 2022. 
 
You asked the Plan to pay for prophylaxis. You say that you want this service covered. 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 February 1, 2022. 
Therefore, we decided that the Plan does not have to pay for prophylaxis (D1110) provided on July 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on December 6, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the codes remain 
not supported. 
 
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. 
 
We looked at the file and Medicare rules. In this case, there are insufficient medical records to show the testing 
was ordered for a specific medical indication. There are no medical records to show the physicians intent for 
the lab testing to be performed. Based on this information, we decided that the Medicare rules for coverage 
have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing services 
provided on December 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for blood smear interpretation (85060) provided on April 26, 
2022. You asked the Plan to pay for blood smear interpretation. You say that this service was necessary and was 
rendered/reported in an appropriate place of service. The Plan denied your request. The Plan says payment 
cannot be made for this service as it was provided to an enrollee in an outpatient hospital setting. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules say that no payment is recognized 
CPT code 85060 furnished to hospital outpatients or non-hospital patients.  
 
We find that CPT code 85060 is not supported for payment. Specifically, this service was provided to an 
enrollee who was in an outpatient hospital setting at the time. Based on this information, we decided that 
Medicare rules for coverage of blood smear interpretation have not been met. Therefore, we decided that the 
Plan does not have to pay for blood smear interpretation (85060) provided on April 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and periodontal 
maintenance (D4910) provided on August 1, 2022, and resin-based composite fillings on tooth #10, 11, 23, 24, 
and 25 (D2330) and a resin-based composite filling on tooth #21 (D2391) provided on August 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says the dental services were received from an out-of-network provider 
and 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. 
 
The record shows you received the requested 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 pay for a comprehensive oral evaluation (D0150) and periodontal maintenance (D4910) provided on August 
1, 2022, and resin-based composite fillings on tooth #10, 11, 23, 24, and 25 (D2330) and a resin-based 
composite filling on tooth #21 (D2391) provided on August 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refractive lens provided on October 1, 2021, billed with 
code V2200. 
 
You asked the Plan to pay for the lens as billed. You say that this should be paid as this is a Medicare-covered 
service. The Plan denied your request. The Plan says the eye exam and refraction testing was approved for 
payment. However, an anatomical modifier was not appended to code V2200, meaning it is not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that when billing for refractive lenses, the anatomical 
modifiers RT or LT must be used. 
 
We looked at the file and Medicare rules. In this case, one unit of V2200 was billed, but a modifier was not 
reported to indicate which eye the lens is to be used for, as required by the rules. Based on this information, we decided that Medicare rules for coverage of the lens as billed have not been met. Therefore, we decided that the 
Plan does not have to pay for the refractive lens provided on October 1, 2021, billed with code V2200.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat sleep study. 
 
You asked the Plan to pre-approve a repeat sleep study. The Plan denied your request. The Plan says the 
request for a repeat sleep study test is not approved. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat polysomnography or sleep testing for 
diagnosing sleep apnea requires documentation justifying the medical necessity for the repeated test. 
 
 
  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 repeat sleep study. Our reviewer says 
that an attended positive airway pressure (PAP) titration study is not medically necessary. Our physician 
reviewer found this enrollee has an established diagnosis of obstructive sleep apnea (OSA), and was previously 
treated with continuous positive airway pressure (CPAP). A repeat diagnostic polysomnography on September 
13, 2022, confirmed OSA. Our reviewer found that the history recorded on September 13, 2022, indicated the 
CPAP was not working well and the enrollee may need a new CPAP. Additional details are not provided. Our 
physician reviewer found that it would be reasonable to resume the previous CPAP therapy at the same 
settings, after replacing or servicing the device as needed. Alternatively, auto-titrating CPAP could be tried. 
Follow-up and device download would be needed to assess compliance and effectiveness of treatment. Our 
reviewer also found that the PAP titration would be needed if CPAP did not resolve the sleep-disordered 
breathing. 
 
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 repeat sleep study have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a repeat sleep study.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 14, 2022, by an OON 
provider. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says the out-of-network 
services were not authorized. 
 
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 June 14, 2022, by an 
OON provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a follow-up sleep study. 
 
You asked the Plan to pre-approve a follow-up sleep study. You say that the enrollee failed a trial of CPAP 
therapy, and a repeat diagnosis is required before new CPAP equipment can be obtained. The Plan denied your 
request. The Plan says this request is not medically necessary because the enrollee has good response with 
CPAP and no settings will need to change with a new CPAP machine. 
 
The Plan follows Medicare rules. Medicare rules say that follow-up polysomnography or sleep studies are not 
routinely indicated for patients treated with continuous positive airway pressure (CPAP) whose symptoms 
continue to be resolved with CPAP treatment. 
 
 
 
 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 follow-up sleep study. Our reviewer 
says that the home polysomnography (PSG) is not medically necessary. Our physician reviewer found this 
enrollee has obstructive sleep apnea (OSA), previously treated with CPAP. The CPAP treatment was 
successful, but the enrollee was unable to achieve minimum compliance, and the device was reclaimed. Our 
reviewer found that the enrollee now has worsening OSA symptoms and wants to try again. Our physician 
reviewer also found that there is no need to confirm the previously made diagnosis, or change positive airway 
pressure settings. 
 
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 follow-up sleep study have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a follow-up sleep study.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor provided on February 11, 
2022. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the 
documentation did not include a valid physician order. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 The record does not contain a valid physician order or relevant medical records which support medical 
necessity for the supplies provided in this case. Based on this information, we decided that the Medicare rules 
for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the continuous 
glucose monitor provided on February 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure. 
 
You asked the Plan to pre-approve the intracept procedure. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the service is experimental. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is an experimental procedure and more research is needed to show its safety and 
efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing amount for the office visit (99211) provided 
on July 28, 2022. 
 
You asked the Plan to waive the cost sharing amount for the evaluation and management service. You say that 
you had a $0 copayment for the prothrombin testing. You say that the testing was transferred to your primary 
care physician (PCP) office. You say that you are now being charged a $10 copayment for the same service. 
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 $10 
copayment for Primary Care Physician (PCP) Service.  
 
You have been asked to pay a $10 copayment for the evaluation and management service. This item/service 
falls within the Primary Care Physician (PCP) Service 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 cost sharing amount for the office visit (99211) provided on July 28, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab services provided on June 3, 2022. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says that the claim 
processed correctly. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has not met its obligation with regards to coordination of benefits. Specifically, the record does not 
show that the Plan has sent the bill directly to the primary insurer for payment, directed the provider to send the 
bill to the primary insurer, or paid for the services and submitted a bill for reimbursement to the primary 
insurer. Therefore, we decided that the Plan has to pay for the lab services provided on June 3, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compressor and segmental pneumatic 
appliance to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a pneumatic compressor and segmental pneumatic appliance. You say that 
the patient has severe pain and swelling and that she is using a non-gradient pump now, but it is not helping. 
The Plan denied your request. The Plan says the enrollee 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 
a pneumatic compressor and segmental pneumatic appliance to be provided by an out-of-network (OON) 
provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound on June 29, 2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you would like to appeal the cost 
share. 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 $125 
copayment for an ultrasound. The allowable amount is less than the $125.00 copayment amount, therefor, the 
member is being charged $104.33.  
 
You have been asked to pay a $125 copayment for an 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 ultrasound on June 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on August 10, 2022, by an 
OON provider. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the out-of-
network services were not authorized. 
 
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 laboratory services provided on August 10, 2022, 
by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 17, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you werent aware that you needed a referral for 
services. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 May 17, 2022, by an 
out-of-network (OON) provider.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve alemtuzumab. 
 
You asked the Plan to pre-approve alemtuzumab. You say that this drug is needed to treat the enrollee's aplastic 
anemia. The Plan denied your request. The Plan says that there is no evidence that the enrollee has either 
multiple sclerosis or chronic leukemia. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Alemtuzumab. Our reviewer says that 
the documentation supports that Alemtuzumab is reasonable and necessary for the enrollee. Our physician 
reviewer found that a consensus protocol for the administration of Alemtuzumab has been published. 
Alemtuzumab is a monoclonal antibody against CD52, which is expressed on lymphocytes and other 
hematopoietic cells. The drug may be administered as a single agent, or in combination with another agent and 
is expected to be safe and effective.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of alemtuzumab have been met. Therefore, we decided that the Plan has to pre-
approve alemtuzumab.  
 
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.