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

 
We decided that the Plan does not have to pre-approve the laparoscopy (CPT code 43644) to be provided by 
out-of-network providers. 
 
You asked the Plan to pre-approve the out-of-network services. You say that you were told by multiple 
representatives that the doctor was in-network with the Plan. The Plan denied your request. The Plan says this 
service is available by a provider in the enrollee's network. The Plan states they found a network provider that 
can perform the same procedure and can see the enrollee within two (2) weeks. 
 
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 
the laparoscopy (CPT code 43644) to be provided by out-of-network providers.
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 
July 6, 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 July 6, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the progressive lenses (V2781) provided on June 1, 2021. 
 
You asked the Plan to pay for the progressive lenses. You say that you would like reconsideration because you 
believed you would at least have partial coverage. The Plan denied your request. The Plan says that progressive 
lenses are not a Medicare covered benefit. 
 
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 does not say in clear and accurate terms 
that progressive lenses would not be covered.  
 
We looked at your contract with the Plan. We did not see where the contract says that progressive lenses are 
not covered. This means that the Plan did not follow Medicare rules for disclosure of information. Therefore, 
we decided that the Plan has to pay for the progressive lenses (V2781) 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tremfya 100MG/ML injection. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the enrollee will obtain the medication from the pharmacy and it will not be 
administered by the physician. The Plan states this medication falls under Part D coverage, but the enrollee has 
no Part D pharmacy benefit with this Health Plan. The Plan states the enrollee has no commercial pharmacy 
benefit administered by this Health Plan. 
 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 Tremfya 100MG/ML 
injection.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
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 transfer to an LTACH is medically 
necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an 
LTACH are not met. The enrollee is receiving appropriate inpatient acute care at the current facility, and these 
services have not been denied. The enrollee is not clinically stable for transfer and does not have conditions 
that cannot be appropriately treated in the current hospital; there are no issues for which an LTACH may offer 
a therapeutic advantage. The Plan will continue to cover medically necessary acute and critical care until the 
enrollee can be moved to a lower level of care or until the clinical circumstances change such that an LTACH 
may be considered. 
 
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 there is no documentation provided indicating medical necessity for the requested 
LTACH services. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where they 
are currently receiving care. There are no services available at the LTACH that the enrollee requires that are 
not available at the health care setting being offered by the health plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 82274, 82656, 82705, 83520, 
83631, 87177, 87209, 87338, 87798, and 89055 provided on November 18, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 codes 82274, 82656, 82705, 83520, 83631, 87177, 87209, 87338, 87798, and 89055 are not 
supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect 
the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory 
specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation 
and/or claim history indicates that the specimen was obtained in an office setting place of service 11.  Based on this information, we decided that Medicare rules for coverage of the laboratory services have not 
been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 82274, 
82656, 82705, 83520, 83631, 87177, 87209, 87338, 87798, and 89055 provided on November 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shingles vaccine you received on July 21, 2021. 
 
You asked the Plan to pay for the vaccine. The Plan denied your request. The Plan says this is not covered 
under your Part B plan. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The 
Plan follows the same rules.  
 
The records do not show that you have been injured or directly exposed to any illness related to the vaccine. 
Therefore, we decided that the Plan does not have to pay for the shingles vaccine you received on July 21, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for special anesthesia service (99100) provided on March 3, 
2021. 
 
You asked the Plan to pay for anesthesia. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for this service is correct, because code 99100 is 
always bundled for payment and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that code 99100 is always bundled for payment, and 
if it is covered the payment for it is subsumed by the payment for the services to which it is incident.  
 
We looked at the file and Medicare rules. This code is always bundled for payment and is not separately 
payable. Based on this information, we decided that Medicare rules for coverage of anesthesia have not been 
met. Therefore, we decided that the Plan does not have to pay for special anesthesia service (99100) provided 
on March 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Libre CGM, for the enrollee. 
 
You asked the Plan to pre-approve the CGM. You say that you are requesting review of denial of services. The 
Plan denied your request. The Plan says the Medicare rules have not been 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 give 
themselves insulin shots three (3) or more times a day. 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 Freestyle Libre CGM, for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (36415, 80202, 82565, 84520) and 
the travel allowance one way in connection with medically necessary laboratory specimen collection drawn 
from a home bound or nursing home bound patient; prorated trip charge (P9604) rendered by the OON 
provider on June 4, 2021, and June 10, 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 the services were rendered by an out of 
network provider, without prior authorization. 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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. 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 the laboratory services (36415, 80202, 82565, 84520) and the travel allowance 
one way in connection with medically necessary laboratory specimen collection drawn from a home bound or 
nursing home bound patient; prorated trip charge (P9604) rendered by the OON provider on June 4, 2021, and 
June 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary for this enrollee's 
recovery. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The 
enrollee's necessary care can be safely provided in an alternate setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 
 Our physician reviewer found that the complexity of the enrollees nursing, medical and rehabilitation needs 
does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While 
the documentation does support a need for physical and/or occupational therapy, there is no documented need 
for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this 
enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MRI, brain (including brain stem); without contrast 
material (CPT code 70551). 
 You asked the Plan to pre-approve the MRI. You say that you had brain surgery four (4) years ago and the 
doctor wants to be sure that the blood vessel has not returned. The Plan denied your request. The Plan says the 
physician order has not been received. The Plan states that you need to obtain a physician order along with 
medical justification with regards to meeting criteria or having medical necessity. The Plan states this is not a 
service that you can obtain without a physicians order or approved referral. The Plan states the treating 
provider needs to order this for you. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the MRI have not been met. The physician order has not been received. Medicare guidance says all 
diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician 
who is treating the beneficiary, that is, the physician who furnishes a consultation or treats a beneficiary for a 
specific medical problem and who uses the results in the management of the beneficiary's specific medical 
problem. Therefore, we decided that the Plan does not have to pre-approve MRI, brain (including brain stem); 
without contrast material (CPT code 70551).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical placement of implant body: endosteal implant 
(D6010), custom fabricated abutment (D6057), and abutment supported porcelain fused to metal crown 
(D6059). 
 
You asked the Plan to pre-approve the endosteal implant, custom fabricated abutment), and abutment supported 
crown. You say that you need to have an implant or bridge and need help from your dental insurance to cover 
these services. The Plan denied your request. The Plan says these services are not covered under your plan. 
 
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 pre-approve a 
surgical placement of implant body: endosteal implant (D6010), custom fabricated abutment (D6057), and 
abutment supported porcelain fused to metal crown (D6059).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interlaminar/interspinous process 
stabilization/distraction device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this procedure has not been shown to be helpful. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found these interlaminar spinous process devices remain experimental. More research is needed to show the 
safety and efficacy of the devices. 
 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an interlaminar/interspinous process stabilization/distraction device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete denture - mandibular (CPT code D5120) and 
complete denture - maxillary (CPT code D5110). 
 
You asked the Plan to pre-approve the dental services. You say that your dentures are too big and do not close 
right. The Plan denied your request. The Plan says you exhausted your benefit frequency limit. 
 
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. Review of the file shows that a 
set of dentures was provided to you on December 10, 2020. The health plan contract says complete dentures 
(upper and lower) (One (1) upper complete and one lower complete denture every five (5) years. Therefore, we 
decided that the Plan does not have to pre-approve complete denture - mandibular (CPT code D5120) and 
complete denture - maxillary (CPT code D5110).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder testing provided on May 14, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that CPT codes 0012M and 0013M for are non-
covered for Cxbladder testing.  
 
We looked at the file and Medicare rules. The requested testing was billed with code 0012M. This is a non-
covered code for Cxbladder testing. 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 Cxbladder 
testing provided on May 14, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy services. 
 
You asked the Plan to pre-approve additional services. The Plan denied your request. The Plan says the 
approved visits will allow you to progress toward long-term goals. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
The file shows that 36 physical therapy visits were requested. The Plan pre-approved 12 visits. 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 services. Our physician reviewer found that 
additional requested therapy is not generally accepted as effective therapy for your condition beyond what was 
approved by the Plan. You have had prior therapy and additional therapy has already been approved.  The documentation does not reveal that the remaining 24 visits are required to provide treatment that can be 
performed only by a therapist, or under the supervision of a therapist without completion of the already 
approved therapy. You have been instructed in a home exercise program. The services of a qualified therapist 
are not required to establish, design or deliver a program to maintain your current condition or to prevent or 
slow further deterioration. 
 
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 services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve additional physical therapy services.