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

 
We decided that the Plan does not have to pay for an office visit provided on June 17, 2022. 
 
You asked the Plan to pay for an office visit. You say that provider and practice are participating with the Plan. 
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 an office visit provided 
on June 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on 
October 17, 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 are excluded 
from Medicare coverage and you are not enrolled in a supplemental dental benefit program. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
 
  The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation 
(D0150) provided on October 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for polycarbonate lenses (V2784) and progressive lenses 
(V2781) provided on September 29, 2022. 
 
  You asked the Plan to pay for polycarbonate lenses (V2784) and progressive lenses (V2781). You say that you 
disagree with this decision. You also say that the insurance is supposed to cover up to $200 per year for vision 
expenses. The Plan denied your request. The Plan says that the vision Plan does not offer a $200 credit to be 
paid out, but that amount is subtracted from the total retail amount. The Plan says that the total charge was 
$329 minus the allowance, leaving $129 ($329-200=$129). The Plan also says that there was a 20% discount 
then applied, leaving your total $103.20 ($129 - 20% = $103.20). 
 
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 up to $200 retail price. 
 
We looked at the file and the Plan's rules. The Plan rules say you are responsible for any amount over the $200 
retail price. The record shows that the Plan subtracted the $200 from the retail price, which left $129 ($329 
retail price - $200 allowance = $129). The record also shows that after the allowance deduction, a 20% 
discount was applied to the lenses, leaving the total $103.20 ($129 - 20% discount = $103.20). Based on this 
information, we decided that the Plan's rules for coverage of polycarbonate lenses (V2784) and progressive 
lenses (V2781) have not been met. Therefore, we decided that the Plan does not have to pay for polycarbonate 
lenses (V2784) and progressive lenses (V2781) provided on September 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental extraction, a cutting procedure, and collection and 
the application of autologous blood concentrate product (D7210, D7250, D7921) provided on September 13, 
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 dental 
extraction, a cutting procedure, and collection and the application of autologous blood concentrate product 
(D7210, D7250, D7921) provided on September 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guidance urinary tract infection (UTI) test provided to 
the enrollee on March 12, 2020. 
 
You asked the Plan to pay for the testing. You say that the services were medically necessary. The Plan denied 
your request. The Plan says this is not a covered benefit. 
 
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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this assay test intended for use in the detection and quantification of bacterial and other pathogenic 
organisms in urine does not meet the requirements for approval. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the Guidance urinary tract infection (UTI) test provided to the enrollee on March 12, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87481 billed for May 26, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 87481 is not supported. 
 
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 87481 is infectious agent detection by nucleic acid (DNA 
or RNA); Candida species, amplified probe technique. 
 
We find that CPT code 87481 is not supported in the medical record. Specifically, the records do not contain 
separate testing/results to support all five Candida groups. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 87481 billed for May 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient surgery provided on April 01, 2022. 
 
You asked the Plan to pay for outpatient surgery. 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 surgery 
provided on April 01, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 Keytruda. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the Food and Drug Administration has not 
stated that the requested drug as prescribed is indicated for the enrollee's condition. The Medicare approved 
cancer drug compendia do not contain a supportive citation for the use of the requested drug as prescribed in 
the enrollee's clinical situation. No literature from Medicare approved cancer journals were submitted for 
review. The elements of the coverage criteria are not satisfied. The requested service cannot be 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 Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for PT visits provided from July 11, 2022, to 
August 29, 2022. 
 
You asked the Plan to waive the copayment for PT visits. You say that the hospital verified several times that 
they would not charge you for services rendered. 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 $35 
copayment for each Medicare covered physical therapy.  
 
You have been asked to pay a total copayment of $385 for PT visits ($35 per visit x 11 visits = $385). This 
item/service falls within 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 from July 11, 2022, to August 29, 2022.  
 Your complaint about the hospital confirming that you would not be charged for PT services 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for end stage renal disease (ESRD) services provided on August 
01, 2022. 
 
You asked the Plan to pay for end stage renal disease (ESRD) services. You say that this was medically 
necessary and should be covered. We depend on the office staff to get prior authorization. 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 end stage renal disease 
(ESRD) services provided on August 01, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377), harness (E2313), electronic connection device (E2311) and power seat elevation feature (E2300).
You asked the Plan to pre-approve an expandable controller, harness, electronic connection device and power seat elevation feature. You say that these items are medically necessary. The Plan denied your request. The Plan says that your upper limb strength and function are adequate to control the wheelchair's power options using their own switches, and a power seat elevation feature is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare rules also say that a power seat elevation feature is non-covered because it is not primarily medical in nature. Our Medical director looked at the case file and the reopen request. At issues is coverage for an expandable controller, harness and electronic connection device. Our Medical Director states that the documentation is insufficient to support that the expandable controller, harness and electronic connection device were medically reasonable and necessary for you in this case. Our physician reviewer found that your condition does not meet criteria for coverage of an expandable controller, harness and electronic connection device. 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 expandable controller, harness, electronic connection device and power seat elevation feature have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377), harness (E2313), electronic connection device (E2311) and power seat elevation feature (E2300).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on February 24, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. The Plan denied your 
request. The Plan says this expense is not covered because the enrollee was not actually transported by the 
ambulance. 
 
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 February 24, 2022. Specifically, the record 
shows that the enrollee refused to be transported. 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 response and treatment with no transport (A0998) provided on 
February 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hot or cold packs therapy (97010), the electrical 
stimulation (97032), and the manual therapy (97140) provided from November 29, 2021, through December 8, 
2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. 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 the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the hot or cold packs therapy (97010), the electrical stimulation (97032), 
and the manual therapy (97140) provided from November 29, 2021, through December 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a peridontal periodic oral evaluation, cleaning, and filling 
(D2331, D1110, D0120) provided on October 24, 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 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 peridontal periodic oral evaluation, cleaning, and filling (D2331, D1110, D0120) provided on 
October 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

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

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

 
We decided that the Plan does not have to pre-approve luspatercept (Reblozyl). 
 
You asked the Plan to pre-approve Reblozyl. You say that the enrollee will benefit from the medication. The 
Plan denied your request. The Plan says the enrollee has not had a transfusion. 
 
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 Reblozyl. Our physician reviewer found 
that the enrollee has myelodysplastic syndromes (MDS) with refractory anemia and ringer sideroblasts. The 
requested use of Reblozyl is not FDA approved for the enrollee's diagnosis. Luspatercept is not indicated for 
use as a substitute for red blood cell transfusions in those who require immediate correction of anemia. The use 
is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved 
medical journal. The documentation does not support that the requested drug is safe and effective and 
otherwise reasonable and necessary for this enrollee. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Reblozyl have not been met. Therefore, we decided that the Plan does not have 
to pre-approve luspatercept (Reblozyl).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional OT sessions. 
 
You asked the Plan to pre-approve additional OT sessions. You say that the additional OT visits are medically 
necessary. The Plan denied your request. The Plan says additional OT visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 
  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 additional OT sessions. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found the member has previously been treated with outpatient 
therapies and should be independent with a home exercise program.  There is no documentation of a recent 
injury or decline in function that hasn't been addressed. The additional therapy services are not an appropriate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional OT sessions have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 10 additional OT sessions.