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

 
We decided that the Plan does not have to pre-approve cataract surgery to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve cataract surgery to be provided by an OON provider. You say that you would like the 
Plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are neither emergent 
nor urgent to seek out-of-network care. The Plan says there are in-network providers available to you that can provide the 
services you are requesting. 
 
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 cataract surgery 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 F2 and F5 genetic testing rendered on March 12, 2020. 
 
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 F2 and F5 germline hereditary mutation tests will be 
considered medically reasonable and necessary when performed for evaluation of venous thromboembolism. 
 
We looked at the file and Medicare rules. The file shows that the F2 and F5 testing was not performed for 
evaluation of venous thromboembolism. Therefore, we decided that the Plan does not have to pay for the F2 
and F5 genetic testing rendered on March 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ankle foot orthosis (L1930) purchased on December 16, 2020. 
 
You asked the Plan to pay for the ankle foot orthosis. You say that you believe this claim should be reprocessed and 
approved for payment by the Plan. The Plan denied your request. The Plan says this provider does not participate with 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not 
enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. 
Therefore, we decided that the Plan does not have to pay for the ankle foot orthosis (L1930) purchased on December 16, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement graft (D4263 x 2), guided tissue 
regeneration (D4266), implants (D66010 x 3), and bone graft at time of implant placement (D6104). 
 
You asked the Plan to pre-approve the dental services. You say that you do not have the money to pay for all of 
these services. You also say that you are experiencing some discomfort with your teeth. The Plan denied your 
request. The Plan says the bone replacement graft, guided tissue regeneration, implants, and bone graft at time 
of implant placement are not listed as covered services. 
 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 dental services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve bone 
replacement graft (D4263 x 2), guided tissue regeneration (D4266), implants (D66010 x 3), and bone graft at 
time of implant placement (D6104).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of an impacted tooth, completely bony, (D7240 
x 3) provided on February 12, 2021. 
 
You asked the Plan to pay for the dental services. You say that you need these services to be covered. The Plan 
denied your request. The Plan says the removal of impacted teeth are not listed as covered services. 
 
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 dental services are not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the removal of an 
impacted tooth, completely bony, (D7240 x 3) provided on February 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crowns (D6750 x 2) and pontics (D6240 x 2). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered. The Plan 
denied your request. The Plan says retainer crowns are not listed as covered services. The Plan says that pontics 
are not listed as covered services either. 
 
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 services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve retainer 
crowns (D6750 x 2) and pontics (D6240 x 2).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for the Medicare Part B prescription drugs provided on 
June 1, 2021. 
 
You asked the Plan to waive the coinsurance for the Medicare Part B prescription drugs. You say that you 
should have only had the $45 copayment for the specialist visit. The Plan denied your request. The Plan says 
that you have been charged the correct cost sharing amount, 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not clearly shown the allowed amounts for the Medicare Part B 
prescription drugs. We are not able to confirm if you have been charged the correct coinsurance amount. 
Therefore, we decided that the Plan has to waive the coinsurance for the Medicare Part B prescription drugs 
provided on June 1, 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve gingival irrigation (D4921 x 4), application of numbing medicine (D9910), biologic materials to aid in soft and osseous tissue regeneration (D4265 x 2), a bone replacement graft (D7953), partial lower denture with flexible base (D5226), occlusal adjustment (D9952), and tissue conditioning (D5851).  You asked the Plan to pre-approve the dental services. You say that [Enter appellant's argument from appeal letter, e.g. "...you need SNF care."] The Plan denied your request. The Plan says the requested dental services are not listed as 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 dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve gingival irrigation (D4921 x 4), application of numbing medicine (D9910), biologic materials to aid in soft and osseous tissue regeneration (D4265 x 2), a bone replacement graft (D7953), partial lower denture with flexible base (D5226), occlusal adjustment (D9952), and tissue conditioning (D5851).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient mental health care provide to the enrollee from 
May 15, 2021, to May 27, 2021. 
 
You asked the Plan to pay for this service. You say that this service should be covered by the Plan. The Plan 
denied your request. The Plan says Medicare coverage criteria are not met. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active 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 pay for this service. 
Our reviewer says that Medicare coverage criteria are not met.  Our physician reviewer found the enrollee was involuntarily admitted to the acute inpatient psychiatric 
hospitalization on May 15, 2021 with Major Depressive Disorder, Recurrent, Moderate and Major 
Neurocognitive Disorder, Unspecified with Behavioral Disturbance. Based upon review the records provided it 
was not expected this enrollee would improve in a reasonable period for the dates in question as she did not 
have suicidal or homicidal ideation noted and denied any auditory or visual hallucinations. The enrollee was 
compliant with treatment while not showing any acute threats to safety. It did not appear medically necessary 
and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of 
care beyond the dates in question as she did not have dangerousness to self or others but was compliant with 
her treatment. The health plan?s denial of continued inpatient psychiatric services is appropriate. This enrollee 
did not appear to require inpatient mental health treatment beyond the date in question as she was not a danger 
to herself or others and did not have any auditory or visual hallucinations while being cooperative with 
treatment. It did not appear that active treatment was taking place beyond the date in question. It did not appear 
that the services were reasonably expected to improve the patient?s condition or for the purpose of diagnosis 
beyond the date in question. Based upon review the records provided for the admission of this patient does not 
meet the criteria for continued acute inpatient mental health treatment for the dates in question of May 24, 2021 
forward as this patient was not shown to be a danger to herself or others. She was not showing any auditory or 
visual hallucinations and was cooperative/compliant with treatment while not showing any threats the safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pay for inpatient mental health care provide to the enrollee from May 15, 2021, to May 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on March 30, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that the service is medically 
necessary. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
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 did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the services at issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care provided on 
March 30, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (procedure code G0483) provided to the enrollee on May 13, 
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 contain documentation to support the coding criteria, as it does not support 22 or more drug classes. 
 
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 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 review has determined that records do not contain documentation to support the coding criteria as it 
does not support 22 or more drug classes. 
 
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 drug testing services (procedure code 
G0483) provided to the enrollee on May 13, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 100 additional routine trips. 
 
You asked the Plan to pre-approve additional trips. You say that the additional trips are medically necessary. 
You say that you need 6 trips per week for your brain and stroke issues. You say that you have no other way to 
get to the doctor. You also say that you are trying to be proactive. The Plan denied your request. The Plan says 
up to 48 one-way trips are covered per calendar year. The Plan also says that the additional 100 one-way trips 
would exceed the calendar benefit year limit.  
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan?s coverage rules apply in this 
case. The Plan covers routine transportation when 48 one-way.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plan?s rules for coverage of routine transportation have not been met. Specifically, the requested trips 
exceed the benefit year limit and are not covered. Therefore, we decided that the Plan does not have to pre-
approve 100 additional routine trips.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the reconstructive surgery provided on April 22, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the reconstructive surgery. You say that the service was medically necessary and 
therefore the claim should be paid. The Plan denied your request. The Plan says the provider is not contracted 
with the Plan. 
 
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 did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the services at issue were urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the reconstructive surgery provided on April 22, 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 dermatology services provided by an opted-out physician on
June 21, 2021.
You asked the Plan to pay for dermatology services. You say that you did not know that this provider opted out
of Medicare and feel that the Plan should pay for some of it. The Plan denied your request. The Plan says the
denial of payment for these services is correct, because this provider has opted out of the Medicare program
and is not payable.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items or services provided directly by a physician or practitioner who has opted out of the program except
in cases involving emergencies or urgently needed care.
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for
dermatology services provided by an opted-out physician on June 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the manual wheelchair, detachable 
armrest, anti-tipping device, wheelchair back cushion, heel loop/holder, wheel lock brake extension, semi-
electric hospital bed, gel mattress pad, walker provided and wheelchair seat cushion from August 19, 2021 to 
August 23, 2021. 
 
You asked the Plan to waive the coinsurance for these items. You say that you would like the Plan to help pay 
for these items. The Plan denied your request. The Plan says that the claim processed 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 20% 
coinsurance for Durable medical equipment and related supplies.  
 
You have been asked to pay a 20% coinsurance for these items. These items fall within the Durable medical equipment 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 manual wheelchair, detachable armrest, anti-tipping device, wheelchair back cushion, heel loop/holder, 
wheel lock brake extension, semi-electric hospital bed, gel mattress pad, walker provided and wheelchair seat 
cushion from August 19, 2021 to August 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
February 17, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The 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 out of network physician services provided to the 
enrollee on February 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lightweight wheelchair (CPT code K0003), adjustable 
height, detachable armrest, complete assembly (CPT code E0973 X 2), anti-tipping device (CPT code E0971 X 
2) and heel loop/holder, any type, with or without ankle strap (CPT code E0951 X 2). 
 
You asked the Plan to pre-approve the lightweight wheelchair and accessories. You say that the requested 
lightweight wheelchair and accessories is medically necessary and beneficial. The Plan denied your request. 
The Plan says your records do not state that your home provides enough access between rooms. Your records 
do not state that your home provides enough moving space. Your records do not state that your home provides 
the right surfaces for the use of the requested wheelchair. Your records do not show that you can use the 
wheelchair on your own. Your records do not say that you cannot use a cane or walker. 
 
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 lightweight wheelchair and 
accessories. Our physician reviewer found the documentation indicates you have a mobility deficit that impairs 
mobility related activity of daily living (MRADLs) in the home. The documentation does not reveal that the 
mobility deficit is not ameliorated by a walker, cane, standard manual wheelchair. While you may have the 
cognition to be able to safely operate a lightweight wheelchair the requested K0003 exceeds your medical need. 
Furthermore, there is no assessment of the home to indicate there is adequate maneuvering space in the home 
for the requested device. As the criteria for the K0003 lightweight wheelchair have not been met per Medicare's 
LCD: Wheelchair Options/Accessories (L33792) the additional coverage for the accessories is not 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 the lightweight wheelchair and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve lightweight wheelchair (CPT code K0003), adjustable 
height, detachable armrest, complete assembly (CPT code E0973 X 2), anti-tipping device (CPT code E0971 X 
2) and heel loop/holder, any type, with or without ankle strap (CPT code E0951 X 2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crowns (D6740) and pontics (D6245 x 2). 
 
You asked the Plan to pre-approve the dental services. You say that the work has already been started. You say 
that you need new crowns on your front teeth. You also say that you need this bridge to replace your missing 
teeth so you can eat properly. The Plan denied your request. The Plan says retainer crowns are not listed as 
covered services. The Plan says that pontics are not listed as covered services either. 
 
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 dental services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
retainer crowns (D6740) and pontics (D6245 x 2).