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

 
We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM) 
transmitter. 
 You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are available from the preferred providers. 
 
The Plan must follow Medicare rules. Medicare rules say that Plans may limit enrollees to preferred providers 
for durable medical equipment and supplies.  
 
We looked at the file and Medicare rules. The requested items are from a non-preferred provider. The services 
are available from one of the Plans preferred providers. 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 
pre-approve a Dexcom G6 continuous glucose monitor (CGM) transmitter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a pain management specialist office visit 
provided on May 12, 2021. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you met with the doctor 
out in the parking lot due to their new COVID-19 procedure. You also say that the doctor only said he could 
not use your magnetic resonance imaging (MRI). The Plan denied your request. The Plan says you have been 
charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for an in-network Level 1 specialist office visit at an independent office.  
 
 The medical records show you had a visit with the provider on May 12, 2021. The record shows this claim was 
approved, and you have a cost sharing amount. You have been asked to pay a $35 copayment for a specialist 
office visit. A specialist office visit falls within the Physician/Practitioner Services, Including Doctors Office 
Visits 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 a pain management specialist 
office visit provided on May 12, 2021.  
 
Your complaint about the billing department and the lack of attention provided is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to make additional payment for the limited oral exam (D0140), the 
resin-based composite filling (D2393), and the panoramic x-ray (D0330) provided on December 22, 2021. 
 
You asked the Plan to make additional payment for the dental services rendered. You say that you feel that this 
should be covered as in-network and more reimbursement should be paid. The Plan denied your request. The 
Plan says you have been reimbursed the network rate for the oral exam. Your coverage indicates that you are 
responsible for the difference between the provider's charge and the Plan's payment. The filling and panoramic 
x-ray are 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, payment for out of network services is 
set at the network rate. Charges exceeding this amount are your responsibility. The Plan also does not cover the 
filling/x-ray you received. Therefore, we decided that the Plan does not have to make additional payment for 
the limited oral exam (D0140), the resin-based composite filling (D2393), and the panoramic x-ray (D0330) 
provided on December 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation rendered on December 21, 2021. 
 
You asked the Plan to pay for these services. You say that you were not satisfied with the previous services. 
The Plan denied your request. The Plan says the services exceeded the benefit limit. 
 
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. The Plan covers one limited 
oral evaluation per plan year.  
 
We looked at the file and the Plan's rules. The file shows that you had a limited oral evaluation on November 
29, 2021 that the Plan covered. The evaluation on December 21, 2021 was performed less than one plan year 
from your previously covered evaluation.  Based on this information, we decided that the Plan's rules for coverage of these services have not been met. 
Therefore, we decided that the Plan does not have to pay for the limited oral evaluation rendered on December 21, 2021.  
 
Your complaint about the previous dental provider is not a valid appeal for dental coverage. This part of your 
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision 
about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay further for the dental services rendered on December 28, 2021. 
 
You asked the Plan to pay further for these services. You say that you disagree with the charges. The Plan 
denied your request. The Plan says the annual benefit maximum has been met. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers supplemental 
dental benefits with an annual benefit maximum of $500.  
 
We looked at the file and the Plans rules. The file shows that you received dental services on December 28, 
2021. You are being asked to pay the remaining balance of $164 for these services, as this amount exceeds 
your $500 annual benefit maximum. Therefore, we decided that the Plan does not have to pay further for the 
dental services rendered on December 28, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergent ambulance services. 
 
You asked the Plan to pre-approve non-emergent ambulance services. You say that with an ambulance it would 
be far easier for the enrollee. You state they have the ability to carry the enrollee safely into the house and 
upstairs, help the enrollee transfer, and they have oxygen if needed. The Plan denied your request. The Plan 
says there are no medical needs required during transport to the enrollee's home. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 non-emergent ambulance services. Our 
physician reviewer found the review has determined that the documentation does not support that other means 
of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) are 
contraindicated for this enrollee. The documentation does not support that the enrollee needs the expertise, 
services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe 
transport. The documentation does not support that the ambulance transport is medically reasonable and 
necessary 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 non-emergent ambulance services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve non-emergent ambulance services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services received on May 5, 2021. 
 
You asked the Plan to pay for the services. You say that you cannot afford this on a fixed income. The Plan 
denied your request. The Plan says the provider is on the Medicare opt out list. 
 
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 dental 
services received on May 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid testing 
provided on November 12, 2021, billed with codes 87801 and 87150. 
You asked the Plan to pay for the services as billed. You say that this claim should be paid in full. The Plan 
denied your request. The Plan says one code was paid; however, the POS code reported is not correct. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services as billed have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the infectious agent detection by nucleic acid testing provided on 
November 12, 2021, billed with codes 87801 and 87150.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance provided on November 16, 2021. 
 
You asked the Plan to pay for the periodontal maintenance. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says periodontal maintenance is not covered 
under the Plan's supplemental dental benefit. 
 
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, periodontal maintenance is not among 
those covered under this benefit.  
 
Therefore, we decided that the Plan does not have to pay for the periodontal maintenance provided on 
November 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lower partial denture rendered on October 29, 2021. 
 
You asked the Plan to pay for these services. You say that you should be able to use the benefit for any dental 
services. The Plan denied your request. The Plan says the services exceeded the benefit limit. 
 
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. The Plan covers one lower 
partial denture every five plan years.  
 
We looked at the file and the Plan's rules. The file shows that you previously received a lower partial denture 
on February 10, 2020. The lower partial denture received on October 29, 2021 was received less than five years 
from your previously covered denture. Based on this information, we decided that the Plan's rules for coverage 
of these services have not been met. Therefore, we decided that the Plan does not have to pay for the lower 
partial denture rendered on October 29, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve physical therapy. You say that you have gone to the recommended provider 
before, but the care there was like going backwards. The Plan denied your request. The Plan says the denial of 
authorization for this service is correct, because this provider is out-of-network with the Plan and you can be 
treated by an in-network physical therapy facility. 
 
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 
physical therapy to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Practitioner Services provided on October 26, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for Practitioner Services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says prior authorization is required for an out-of-network 
office 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 Practitioner Services 
provided on October 26, 2021 by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says rules for SNF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found based on the medical records provided there is 
no documentation that the patient requires skilled nursing services, i.e., the specialized skill, knowledge and 
judgment of a skilled professional nurse are not required to safely and effectively provide medically necessary 
and reasonable treatment. Records do not document the need for intravenous medications, new tube feeding, or 
ostomy care or daily complex wound care. While this patient does require skilled therapy services, these 
services are not medically necessary on a daily basis. In conclusion, there is no documentation that the patient 
requires the services on an inpatient basis, only in a skilled nursing facility setting. Records do not document 
that services in the long-term care facility on a part time basis are not appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified mass spectrometry services provided along 
with drug testing on August 11, 2021, billed with code 83789. 
 
You asked the Plan to pay for the unspecified mass spectrometry services. You say that these services should 
be paid. The Plan denied your request. The Plan says the testing was paid but code 83789 is not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing.  
We looked at the file and Medicare rules. We find that the code 83789 is used to represent specimen validity 
testing which is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the unspecified mass spectrometry services have not been met. Therefore, we decided that the Plan does not 
have to pay for the unspecified mass spectrometry services provided along with drug testing on August 11, 
2021, billed with code 83789.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two retainer crowns (D6750) and the two pontics 
(D6240) you received on November 23, 2021. 
 
You asked the Plan to pay for the retainer crowns and pontics. You say that you were told that these services 
were covered. The Plan denied your request. The Plan says these services are not listed as covered benefits in 
your dental contract. 
 
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. Your contract says that any 
dental services not included in the Dental Schedule of Benefits are not covered. Neither the retainer crowns 
(D6750) nor the pontics (D6240) are listed as covered benefits. 
 
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 two 
retainer crowns (D6750) and the two pontics (D6240) you received on November 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on November 30, 
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 this service should not be unbundled. 
 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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for imaging services provided to the enrollee on November 30, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Avastin. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has choroidal melanoma. 
The Food and Drug Administration (FDA) has not stated that the requested drug is indicated for the enrollee's 
condition. The Medicare approved cancer drug compendia do not contain a supportive citation for the use of 
the requested drug in the enrollee's clinical situation. Avastin is not reasonable or medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Avastin.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint medial branch blocks. 
 
You asked the Plan to pre-approve medial branch blocks. You say that this is medically necessary for the 
enrollee's low back pain. The Plan denied your request. The Plan says this procedure is not covered given the 
enrollee's medical history based on Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that facet joint procedures performed after anterior 
lumbar interbody fusion or ALIF are considered not reasonable and necessary and therefore will be denied. 
Based on this information, we decided that Medicare rules for coverage of medial branch blocks have not been 
met. Therefore, we decided that the Plan does not have to pre-approve facet joint medial branch blocks.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional transportation. 
 
You asked the Plan to pre-approve additional trips. You say that you need to get to your dialysis treatment. The 
Plan denied your request. The Plan says you have exhausted your benefit. 
 
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 Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way trips per year.  
 
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional transportation.