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

 
We decided that the Plan does not have to pre-approve the follow-up visit to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that you are unable to return to your 
in-network physicians. You state that you are too weak to drive back to California in order to receive in-
network care. You state you are unsure how long you will be in Arizona, as you were visiting your daughter at 
the time of the emergency room admission. The Plan denied your request. The Plan says you have been 
redirected and approved for services with an in-network pulmonologist in California. 
 
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 provider at issue in this case is not a network provider with the Plan. 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 out-of-network services.  Our physician reviewer found there was no documentation to support your inability to return to California (CA) 
for follow-up, nor was there any indication an urgent follow-up was needed based on the emergency 
department (ED) notes. Nodules of the size measured on computed tomography (CT) can be followed up at 3-6 
months (repeat CT), and you did not have an acute condition which required earlier follow-up with a 
pulmonologist 
 
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 out-of-network services have not been met.  
 
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 the out-of-network services. Therefore, we decided 
that the Plan does not have to pre-approve the follow-up visit to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
December 10, 2021. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that you would like to appeal this 
service because you did not need a comprehensive oral evaluation, but only needed a routine evaluation and 
cleaning. You also say that the dentist office is saying you received a comprehensive oral evaluation, but you 
believe you did not receive a comprehensive exam. The Plan denied your request. The Plan says your benefit 
maximum has been met for comprehensive oral exams. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, comprehensive oral exams are limited 
to one every 36 months. The record shows that you received a comprehensive oral evaluation (D0150) on 
January 8, 2020 and your comprehensive oral exams benefit has been exhausted. Therefore, we decided that the 
Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on December 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), bitewing x-rays 
(D0274), and prophylaxis (D1110) provided on October 26, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the periodic oral evaluation, bitewing x-rays, and prophylaxis. You say that you 
have been going to this same dental office for five years without a payment denial from the Plan, and you feel 
the claim denial is unwarranted and incorrect. The Plan denied your request. The Plan says services performed 
by an OON provider are not covered because your healthcare plan does not have OON benefits. The Plan also 
says that you did not contact the Plan prior to this date of service to verify benefits and provider eligibility. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for 100% of the 
cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay 
for the periodic oral evaluation (D0120), bitewing x-rays (D0274), and prophylaxis (D1110) provided on 
October 26, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia for open or surgical arthroscopic procedures 
(01630) and an anesthetic or steroid injection into the brachial plexus (64415) billed for date of service 
December 6, 2021. 
 
You asked the Plan to pay for anesthesia for open or surgical arthroscopic procedures and an anesthetic or 
steroid injection into the brachial plexus. You say that the services at issue were a medical necessity for the 
enrollee. The Plan denied your request. The Plan says the available 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 01630 is "Anesthesia for open or surgical arthroscopic 
procedures on humeral head and neck, sternoclavicular joint, acromioclavicular joint, and shoulder joint; not 
otherwise specified" and the definition of code 64415 is "Injection(s), anesthetic agent(s) and/or steroid; 
brachial plexus." 
 
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 anesthesia for open or surgical arthroscopic procedures and 
an anesthetic or steroid injection into the brachial plexus. Our reviewer says that the services at issue do not 
meet criteria for reimbursement. Our reviewer found that, with regard to CPT code 01630, the documentation 
includes an anesthesia graph, with time documented; however, the anesthesia procedure does not document 
start and stop time for anesthesia services and therefore the procedure cannot be verified. With regard to CPT 
code 64415, the record does not include documentation of an injection to confirm that this procedure was not 
inclusive to the anesthesia given. Therefore, this procedure also cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of anesthesia for open or surgical arthroscopic procedures and an anesthetic or 
steroid injection into the brachial plexus have not been met. Therefore, we decided that the Plan does not have 
to pay for anesthesia for open or surgical arthroscopic procedures (01630) and an anesthetic or steroid injection 
into the brachial plexus (64415) billed for date of service December 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electrical bone growth stimulator. 
 
You asked the Plan to pre-approve an electrical bone growth stimulator. You say that the requested device is 
medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been 
satisfied. 
 
The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for nonunion 
of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs 
have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the 
electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs 
separated by a minimum of 90 days.  
 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 electrical bone growth stimulator. 
Our reviewer says that the requested device is not medically reasonable and necessary. Our physician reviewer 
found that the documentation does not reveal a failed fusion, where a minimum of 9 months has elapsed since 
the last surgery; congenital pseudarthroses; or that this bone stimulator is being used an adjunct to spinal fusion 
surgery for patients at high risk of pseudarthrosis due to previously failed spinal fusion at the same site or for 
those undergoing multiple level fusion. The patient's lumbar surgery is not a 3 or more level surgery. There has 
been no prior history of failed spinal fusion at the same site. An electric bone growth stimulator is not 
medically necessary per Medicare coverage criteria. 
 
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 electrical bone growth stimulator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an electrical bone growth stimulator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower 
denture (D5120) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a complete upper denture and a complete lower denture. You say that you 
were advised by two different Plan representatives that your partial dentures would be covered and to send in 
the estimate. You also say that you do not have any teeth and you are unable to eat which has affected your 
nutrition and weight. The Plan denied your request. The Plan says dental services are only covered when 
performed by a participating general dentist. The Plan also says that the requested services are not listed codes 
and therefore not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 pre-approve a 
complete upper denture (D5110) and a complete lower denture (D5120) to be provided by an out-of-network 
(OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical pathology services rendered on May 20, 2021. 
 
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 the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that the PC and TC for diagnostic services are separately 
payable when furnished in different payment localities. 
 
We looked at the file and Medicare rules. The file shows that the PC and TC were not performed in different 
payment localities. 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 the surgical pathology services 
rendered on May 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the thoracentesis, needle or catheter, aspiration of the 
pleural space; with imaging guidance (CPT code 32555) to be provided by a tertiary care level provider. 
 
You asked the Plan to pre-approve the services. You say that you do not want to have another group do 
something that is detrimental to your health. You state that you have been going to this facility for procedures 
for years for cancer treatments and chemotherapy and do not need to start all over with another provider. The 
Plan denied your request. The Plan says your medical records do not show that you have an emergent or urgent 
condition, or are in need of specialized service, and have providers within your network that can provide your 
care. 
 
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 provider at issue in this case is not a network provider with the Plan. 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 services. Our physician reviewer found the provided records did not 
clearly show that this procedure was urgent or that it must be performed at the requested location. You could 
effectively and safely have thoracentesis at an in-network location. 
 
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 services have not been met.  
 
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 the services. Therefore, we decided that the Plan does 
not have to pre-approve the thoracentesis, needle or catheter, aspiration of the pleural space; with imaging 
guidance (CPT code 32555) to be provided by a tertiary care level provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid (V5261) purchased on October 13, 2021. 
 
You asked the Plan to pay for hearing aids. You say that these services should be covered. The Plan denied 
your request. The Plan says hearing aids are not covered by Medicare or by your Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related 
services.  
 
Though hearing aids may be appropriate in this case, neither Medicare nor the Plan covers or pays for these 
types of items and services. Therefore, we decided that the Plan does not have to pay for the hearing aid 
(V5261) purchased on October 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and 
interpretation (D0364) provided on January 5, 2022. 
 
You asked the Plan to pay for the cone beam CT capture and interpretation. You say that you are denying 
responsibility for this service because your dentist should have checked for your coverage. The Plan denied 
your request. The Plan says this service is not covered under the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 cone 
beam computed tomography (CT) capture and interpretation (D0364) provided on January 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the monitoring services rendered on October 14, 2021. 
 
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 95941 is not covered. 
 
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 find that CPT code 95941 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code 95941 is not valid for Medicare purposes. 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 the 
monitoring services rendered on October 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
April 22, 2021. 
 
You asked the Plan to pay for dental services. You say that you were in a location, and you needed these services 
done. The Plan denied your request. The Plan says services provided by out-of-network providers are not 
covered benefits. The Plan says that services provided out of the United States are only covered in emergency 
situations. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 dental 
services provided by an out-of-network provider on April 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on October 11, 2021. 
 
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 the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that all ESRD-related laboratory services are included in 
the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid. 
 
We looked at the file and Medicare rules. The file shows that the laboratory services were rendered for end-
stage renal disease (ESRD). Payment is included in the payment to the ESRD facility. Therefore, we decided 
that the Plan does not have to pay for the laboratory services rendered on October 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the electronic connection between wheelchair controller 
and one power seating system motor, including all related electronics, indicator feature, mechanical function 
selection switch, and fixed mounting hardware (E2310). 
  
You asked the Plan to pre-approve the electronic connection. You say that you would like reconsideration 
because this accessory is medically necessary. The Plan denied your request. The Plan says this accessory is 
not medical in nature. 
 
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 electronic connection. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the electronic connection exceeds the enrollee's medical needs as the patient does not 
need to control two or more of the following motors from a single interface. 
 
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 electronic connection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the electronic connection between wheelchair controller and one power 
seating system motor, including all related electronics, indicator feature, mechanical function selection switch, 
and fixed mounting hardware (E2310).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a personal item hook for a power wheelchair. 
 
You asked the Plan to pre-approve a personal item hook. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says this item does not serve a medical need 
and cannot be covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a personal item hook for a power wheelchair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found you are receiving appropriate care at the present acute care hospital. There are no 
services available at the LTACH that you require that are not available at the health care setting being offered 
by the health plan. The requested LTACH services medically necessary, reasonable, and appropriate for your 
diagnosis and condition and able to be furnished safely and effectively only on an inpatient basis. 
 
 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Methocarbamol for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that the enrollee has been stable on this medication. The 
Plan denied your request. The Plan says that this is not covered under 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 Methocarbamol for the 
enrollee.  
 Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.