Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on August 22, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for wound care supplies. You say that you would like to request reconsideration of 
the denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-network. 
 
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 wound care supplies provided on August 22, 2022, 
by an out-of-network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme. 
 
You asked the Plan to pre-approve Feraheme. 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. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Feraheme. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the Plan requires a trial of drug Ferrlecit, 
Infed or Venofer before they will approve the requested drug. In this case, the enrollee has not tried and failed 
the required drugs. There is no documentation provided indicating that the plans required drugs would likely 
be less effective and/or likely have adverse effects for the 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 Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the aquatic membership/services provided January 1, 2022, 
through April 30, 2022. 
 
You asked the Plan to pay for the aquatic services. You say that you swim for aerobic exercise. The Plan 
denied your request. The Plan says aquatic services are not covered under your benefits. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
only for approved memberships or instructional fitness classes. 
 
The Plans rules for coverage of gym benefits have not been met because aquatic services are not covered 
under this benefit. Therefore, we decided that the Plan does not have to pay for the aquatic 
membership/services provided January 1, 2022, through April 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for debridement provided on April 5, 2022, by an OON 
provider. 
 
You asked the Plan to pay for the debridement. You say that it is not always possible to obtain an authorization 
for every visit prior to the provider rendering the services, which means we will send the medical records to 
support the necessity of providing the service to the member. 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 debridement provided on April 5, 2022, by an 
OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) and extraction 
of tooth #32 (D7210) provided by an oral surgeon. 
 
You asked the Plan to pre-approve an evaluation and extraction. You say that these services are medically 
necessary. The Plan denied your request. The Plan says the requested items or services are not covered when 
received by an oral surgeon. 
 
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 when received by an oral surgeon. Therefore, we decided that the Plan 
does not have to pre-approve a comprehensive oral evaluation (D0150) and extraction of tooth #32 (D7210) 
provided by an oral surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675, E0673) provided 
on May 11, 2022, to May 17, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that this device was medically 
necessary. The Plan denied your request. The Plan says the claim was billed with an invalid place of service. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism is a preventive service. The rules also say that a PCD coded 
as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675, E0673) provided on May 11, 2022, to May 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prostate artery embolization. 
 
You asked the Plan to pre-approve prostate artery embolization. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 prostate artery embolization. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found prostatic arterial embolization (PAE) is not medically reasonable and 
necessary in this case. Prostatic arterial embolization (PAE) is considered an experimental technique to treat 
symptomatic benign prostatic hyperplasia (BPH). Very limited studies have demonstrated possible short-term 
safety and efficacy. The most recent AUA guidelines do not recommend this procedure outside of a clinical 
trial setting due to the heterogeneity in the available literature and safety concerns regarding radiation 
exposure, postembolization syndrome, vascular access, technical feasibility, higher clinical failure rate 
compared with more traditional methods. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of prostate artery embolization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve prostate artery embolization.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assisted living facility services provided on July 5, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for assisted living facility services. You say that the services provided were 
medically necessary. 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 assisted living facility services provided on July 5, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on May 11, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the rendering physician is a 
hospitalist physician with the group and depends upon the hospital staff to verify eligibility and to obtain the 
proper authorization from the patient's insurance company. The Plan denied your request. The Plan says 
services from non-participating providers are not covered under the Plan unless they are authorized by the Plan 
before the services are provided. 
 
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 subsequent nursing facility care provided on May 
11, 2022, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on April 20, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility. You say that the provider is listed as the facility and 
should be under the physician, who is in-network. The Plan denied your request. The Plan says the decision 
was based on  how the claim was submitted and processed. The provider is not a contracted provider 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 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 subsequent nursing facility care provided on April 
20, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SelectMDx test (81479) provided on October 20, 
2021. 
 
You asked the Plan to pre-approve the SelectMDx test. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this service was performed as a screening test and is therefore not 
covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered.  
The test at issue in this appeal, the SelectMDx test, is being requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pre-
approve the SelectMDx test (81479) provided on October 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services provided on June 22, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for outpatient hospital services. You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says the provider is out-of-network, and it 
was determined these services can be received in-network. 
 
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 outpatient hospital services provided on June 22, 
2022, by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services on July 24, 2022. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you would like to 
appeal the cost share. The Plan denied your request. The Plan says 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 $50 
copayment for emergency room services.  
 
You have been asked to pay a $50 copayment for emergency room services. This item/service falls within the 
emergency room 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 emergency 
room services on July 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro orthosis for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the device is unlikely to result in a level of functional independence. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that although records from the device manufacturer/vendor argue medical necessity of the requested 
device, records from the enrollee's actual treating provider do not clarify why the requested device is the most 
appropriate treatment for the enrollee's condition. In addition, provided records report left shoulder subluxation 
and left upper extremity spasticity which may be contraindications to use of the 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the MyoPro orthosis for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on March 21, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the provider is listed as the facility 
and should be under the physician, who is in-network. The Plan denied your request. The Plan says based on 
how the claim was submitted and processed, the rendering physician was not a contracted provider with the 
Plan as of the date of service. 
 
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 subsequent nursing facility care provided on 
March 21, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom foot orthotics (L3000). 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says these items are not a covered benefit under your 
contractual policy or by Medicare for your condition. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve custom foot orthotics (L3000).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 2, 2022, by an OON 
provider. 
 
You asked the Plan to pay for an 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 August 2, 2022, by an 
OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on June 30, 2022. 
 
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent 
or emergent, nor were they approved in advance. 
 
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 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a domiciliary, rest home visit provided on June 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intermittent limb compression device (code E0676) 
provided on January 10, 2022. 
 
You asked the Plan to pay for code E0676. You say that this device was ordered to prevent deep vein 
thrombosis after surgery. The Plan denied your request. The Plan says this item is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that intermittent limb compression devices (E0676) 
are non-covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code E0676 have not been met. Therefore, we decided that the Plan does not have to pay for the 
intermittent limb compression device (code E0676) provided on January 10, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services (90791, 90837) provided on 
April 25, 2022, to May 25, 2022. 
 
You asked the Plan to pay for the outpatient mental health services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says this provider is not eligible for Medicare payment. 
 
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 outpatient 
mental health services (90791, 90837) provided on April 25, 2022, to May 25, 2022.