Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient mental health care to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve outpatient mental health care. You say that you have been unable to find 
another provider that can meet your needs and this provider was recommended to you. 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 provider. 
 
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 
outpatient mental health care to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
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 criteria for coverage are not 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 treat with 
insulin three or more times per day. 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 
continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture (D5225) and mandibular 
partial denture (D5226). 
 
You asked the Plan to pre-approve the partial dentures. The Plan denied your request. The Plan says these 
services 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, 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 
maxillary partial denture (D5225) and mandibular partial denture (D5226).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro Motion G orthotic device (L8702).

You asked the Plan to pre-approve the orthotic device. You say that the device requested is safe and effective. The MyoPro is appropriate for the enrollee including for the duration and frequency. The Plan denied your request. The Plan says this item is considered experimental and investigational. There is insufficient evidence of its effectiveness in those with stroke and hemiparesis.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. 

We looked at this the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-approve the MyoPro Motion G orthotic device (L8702).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for steroid injections provided from April 20, 
2021, to May 20, 2021. 
 
You asked the Plan to waive the copayments for steroid injections. You say that you were not aware that you 
would owe such a high fee and would not have received the services had you known. The Plan denied your 
request. The Plan says the claims were processed correctly and you are being charged the correct 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 $250 
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities. 

You received steroid injections at an outpatient hospital facility from April 20, 2021, to May 20, 2021, for a 
total of 3 services. Steroid injections are considered outpatient surgical procedures. Therefore, you are 
responsible to pay a $250 copayment per each injection. The total amount you owe is: $750.  
 
You have been asked to pay the total copayment amount of $750 for steroid injections. Steroid injections fall 
within the outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical centers 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 copayments for steroid 
injections provided from April 20, 2021, to May 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out-of-network behavioral health services received from June 
24, 2021, to June 28, 2021. 
 
You asked the Plan to pay for the services. You say that you were not aware that the services were out-of-
network. The Plan denied your request. The Plan says there is a requirement to use contracted, in-area 
providers. 
 
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 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 out-of-network behavioral health services received 
from June 24, 2021, to June 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT). 
 
You asked the Plan to pre-approve proton beam radiation therapy. You say that there is strong evidence to 
support the use of proton therapy for prostate cancer. The Plan denied your request. The Plan says the denial of 
authorization for this service is correct, because this is not the standard of care and proton beam therapy for 
prostate cancer should only be performed within the context of a prospective clinical trial. 
 
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 proton beam radiation therapy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found although proton beam therapy is not an experimental therapy, any potential 
benefit or detriment of proton therapy over standard intensity-modulated radiation therapy (IMRT) is an 
investigational question. Other treatment approaches are also highly effective and well tolerated. Thus, whether 
proton therapy affords a benefit over other standard approaches for the enrollee's condition is an area of 
investigation and remains controversial. The generally accepted standard of care for prostate cancer is to only 
offer proton beam therapy in clinical trials, and to not routinely offer it to patients. Proton therapy would 
arguably exceed the enrollee's medical needs. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam radiation therapy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve proton beam radiation therapy (PBRT).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on March 11, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are 
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 testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this 
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab 
services provided on March 11, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia provided June 28, 2021. 
 
You asked the Plan to pre-approve Prolia. You say that the requested drug is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the requested procedure was not medically 
necessary based on the Medicare rules. 
 
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 Prolia. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found the record indicates 
that the enrollee has osteoporosis. The Food and Drug Administration has not stated that the requested drug is 
indicated for the enrollee's condition. The Medicare approved drug compendia do not contain a supportive 
citation for the use of the requested drug in the enrollee's clinical situation. The record provided does not 
establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The 
elements of the coverage criteria are not satisfied. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia provided June 28, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH 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 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 medically necessary. Our physician reviewer found you were admitted to
the hospital with urosepsis. You are receiving acute care services, and these have not been denied. The medical
record does not indicate that you require services that you are not currently receiving but that would be
available at the LTACH facility. The LTACH services are not reasonable or 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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam (D0120) and prophylaxis (D1110) provided on
June 24, 2021.

You asked the Plan to pay for the dental services. You say that the letter you received in the fall of 2020
indicated that if you wanted to keep your dental coverage, you did not have to do anything. You say that it was
not obvious that you needed to opt-in to continue receiving dental coverage. You also say that you these
services should be covered. The Plan denied your request. The Plan says you did not enroll in the optional
supplemental dental coverage. The Plan also says that routine dental services are not covered by Medicare.

Medicare generally does not cover dental services. The Plan follows the same rule.

The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid
for by Medicare.

The record shows that the Annual Notice of Change says that routine and comprehensive dental coverage will
no longer be available as of January 1, 2021, unless you select the optional supplemental dental coverage. The
record shows that you did not enroll in the optional supplemental dental coverage. Therefore, we decided that
the Plan does not have to pay for the oral exam (D0120) and prophylaxis (D1110) provided on June 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.

You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says you are not on insulin.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and 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 assesses 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 use insulin with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on March 3, 2021.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or proprietary laboratory analysis CPT code.

We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple code. Per Medicare rules, the testing should be reported with one unit of one CPT code. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on March 3, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy
assistant on May 5, 2021.

You asked the Plan to pay for the physical therapy services. You say that you attached the medical records
required to reprocess the denied claim. The Plan denied your request. The Plan says the code is not appropriate
for the service.

The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (PTA)
shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they
do not meet the qualifications of a therapist.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the physical therapy services have not been met. Specifically, the billing provider is a nurse
practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's
professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services
provided by a physical therapy assistant on May 5, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on June 8, 2021.

You asked the Plan to waive the copayment for ambulance services. You say that you were forced to take the ambulance and disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $300 copayment for ambulance services. 

You have been asked to pay a $300 copayment for ambulance services. Ambulance services fall within the ambulance 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 ambulance services provided on June 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an auricular electro-acupuncture nerve stimulator.

You asked the Plan to pre-approve an auricular electro-acupuncture nerve stimulator. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the device is not covered by Medicare or the Plan.

The Plan must follow Medicare rules. Medicare rules say that auricular nerve stimulators are considered electro-acupuncture devices which are noncovered by Medicare. Therefore, we decided that the Plan does not have to pre-approve an auricular electro-acupuncture nerve stimulator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the bone replacement graft (D7953).

You asked the Plan to pre-approve the bone replacement graft (D7953). The Plan denied your request. The Plan says the service is not a covered 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, 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 the bone replacement graft (D7953).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain fused to predominantly base metal crown (D2751).

You asked the Plan to pre-approve the crown. You say that you are in extreme pain, and this is the only way to save the tooth. The Plan denied your request. The Plan says D2740 for tooth #20 was paid for on May 5, 2021.

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 crowns once every sixty months (five years). 

A crown was last received less than five years ago on May 5, 2021. Based on this information, we decided that the Plan's rules for coverage of the crown have not been met. Therefore, we decided that the Plan does not have to pre-approve a porcelain fused to predominantly base metal crown (D2751).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone replacement grafts (D4263) and guided tissue regenerations (D4266).

You asked the Plan to pre-approve the bone replacement grafts and guided tissue regenerations. You say that these services are necessary to be able to carry out the approved dental services. The Plan denied your request. The Plan says these services are not covered under your 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. 

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 bone replacement grafts (D4263) and guided tissue regenerations (D4266).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper denture (D5213).

You asked the Plan to pre-approve the dental service. You say that the service should be covered. The Plan
denied your request. The Plan says dentures are covered once every 5 years. The Plan also says that the
frequency limit has been reached.

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 and dentures are listed as covered, the
frequency limit has been reached. The record shows that the Plan paid for a partial upper denture that you
received on January 21, 2019. Therefore, we decided that the Plan does not have to pre-approve a partial upper
denture (D5213).