Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve massage therapy services. 
 
You asked the Plan to pre-approve massage therapy services. You say that this is necessary for your medical 
condition. The Plan denied your request. The Plan says these services are not covered when performed by a 
massage therapist. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pre-approve massage therapy services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for two extractions, erupted tooth, or exposed 
root (D7140) provided on February 14, 2022. 
 
You asked the Plan to waive the coinsurance for the two extractions. You say that you were told you were 
covered for simple tooth extractions. The Plan denied your request. The Plan says the coinsurance was applied 
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 there is a maximum 
$3,000 allowance with 50% coinsurance after the $50 dental deductible every year for supplemental 
comprehensive services.  
 
 
  You have been asked to pay $85 ($50 dental deductible + $35 coinsurance) for the two extractions. The two 
extractions fall within the Comprehensive Dental 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 coinsurance for two extractions, erupted tooth, or exposed root (D7140) provided on February 14, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pluvicto. 
 
You asked the Plan to pre-approve Pluvicto. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested use is not supported. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Pluvicto. Our reviewer says that the 
requested use of Pluvicto is not supported. Our physician reviewer found the record indicates that the enrollee 
has a diagnosis of metastatic castrate resistant prostate cancer. The record does not indicate that the enrollee 
has failed taxane therapy. The Food and Drug Administration has not stated that the requested drug is indicated 
for the enrollee's condition, and the Medicare-approved cancer drug compendia do not support the use of the 
requested drug in the enrollee's clinical situation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Pluvicto have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Pluvicto.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a core-build up (D2950) and a crown (D2740), provided by a 
participating provider on April 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that the Plan should pay for this. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your annual dental maximum allowance amount has been met and exhausted. Therefore, we decided that 
the Plan does not have to pay for a core-build up (D2950) and a crown (D2740), provided by a participating 
provider on April 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation with an endodontist. 
 
You asked the Plan to pre-approve a consultation. You say that if you were treated sooner than you would not 
have to see an endodontist. The Plan denied your request. The Plan says this service is not covered when 
received by an endodontist. 
 
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 endodontist. Therefore, we decided that the Plan 
does not have to pre-approve a consultation with an endodontist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cone beam imaging (D0364) provided on February 7, 2022. 
 
You asked the Plan to pay for imaging. You say that you disagree with the denial of dental services. The Plan 
denied your request. The Plan says cone beam imaging (D0364) is not covered by your routine dental benefits. 
 
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 pay for cone 
beam imaging (D0364) provided on February 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for urine PCR testing (0012M). 
 
You asked the Plan to pay for urine PCR testing. You say that you believe the combination of the medical 
records and strong peer-reviewed publications along with the support of Novitas/CMS LCD coverage is 
sufficient evidence to rule in our favor and provide payment for this claim. The Plan denied your request. The 
Plan says they cannot determine how the enrollee came to the servicing provider, or whether the services are 
medically necessary. 
 
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 pay for urine PCR testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee returns without complaint and with a low international prostate symptom score 
following August 2021 resection of a bladder polyp found to be nonmalignant. He has no constitutional or 
urological complaints. There is no specific clinical rationale provided for the requested laboratory study. The 
plan was still awaiting submission of missing documentation, in the form of test requisition, testing results and 
physician consultation/progress note that provides the indication for CxBladder Testing. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of urine PCR testing have not been met. Therefore, we decided that the Plan does 
not have to pay for urine PCR testing (0012M).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI), brain, without 
contrast (70551), MRI of brain with contrast (70552), and MRI of brain without contrast followed by with 
contrast (70553). 
 
You asked the Plan to pre-approve the MRIs. You say that the requested services are medically necessary. The 
Plan denied your request. The Plan says the requested MRIs are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
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 the MRIs. Our reviewer says that the 
requested MRIs are not medically necessary. Our physician reviewer found the provided documentation does 
not indicate there were red flag signs or symptoms discovered nor a hearing test to warrant advanced imaging 
at this time. Therefore, the reviewer found that the requested MRIs are not medically reasonable or necessary at 
this time. 
 
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 MRIs have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI), brain, without contrast (70551), MRI of brain with contrast 
(70552), and MRI of brain without contrast followed by with contrast (70553).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve the requested item. You say that it is an inconvenience not having a portable 
concentrator. The Plan denied your request. The Plan says you have not had a failure of the current oxygen 
system. 
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system.  
 
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 requested item. Our physician 
reviewer found that you have chronic respiratory failure with hypoxia, as well as heart disease, ischemic 
cardiomyopathy, and chronic kidney disease. The available clinical documentation in the case file does not 
support that you would benefit from the use of portable oxygen in the home. The clinical documentation does 
not support that a portable oxygen concentrator is medically reasonable and necessary 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 the requested item have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a portable oxygen concentrator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a comprehensive oral evaluation (D0150) 
and a panoramic x-ray (D0330) provided on April 8, 2022, and periodontal scaling and root planing (D4341) 
provided on April 19, 2022. 
 
You asked the Plan to waive the coinsurance for the dental services. You say that you would like these services 
to be reprocessed at the in-network rate. 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 50% 
coinsurance for out-of-network preventive and comprehensive dental services.  
 
The record shows you received dental services from an out-of-network provider. You have been asked to pay 
$24, which is 50% coinsurance of the allowed amount for an evaluation provided on April 8, 2022 ($48 
allowed amount x 50% coinsurance = $24). You have also been asked to pay $40, which is 50% coinsurance of 
the allowed amount for an x-ray provided on April 8, 2022 ($80 allowed amount x 50 % coinsurance = $40). 
You have also been asked to pay $87, which is 50% coinsurance of the allowed amount for periodontal scaling 
provided on April 19, 2022 ($174 allowed amount x 50% coinsurance = $87). An evaluation, x-ray, and 
periodontal scaling falls within the Dental 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 
coinsurance for a comprehensive oral evaluation (D0150) and a panoramic x-ray (D0330) provided on April 8, 
2022, and periodontal scaling and root planing (D4341) provided on April 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), prophylaxis (D1110), 
and a resin-based composite (D2393) from February 9, 2022, to March 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental benefits. 
 
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 record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation (D0120), prophylaxis (D1110), and a resin-based composite (D2393) from 
February 9, 2022, to March 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PCR testing provided on December 10, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the panel tested 6 or 
more pathogens. 
 
The Plan follows Medicare rules. Medicare rules say that Multiplex PCR respiratory viral panels of 6 or more 
pathogens are non-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 pay for the testing. Our reviewer says that the billed 
services are not payable. Our physician reviewer found that the requested testing exceeds the pathogen limit. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the PCR testing provided on December 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composite fillings (D2330, D2331) and sales tax 
(D9985) provided on March 31, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says the dental services were received from an out-of-network provider 
and are not covered by your supplemental benefits. 
 
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 record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for resin-based composite fillings (D2330, D2331) and sales tax (D9985) provided on March 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power wheelchair for the enrollee. 
 
You asked the Plan to pre-approve a Group 2 power wheelchair. You say that the patient is immobile, has no 
range of motion cannot use crutches or manual walker. The Plan denied your request. The Plan says that 
records do not show the enrollee is unable to use a scooter to complete his MRADLs in the home. 
 
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 a Group 2 power wheelchair. Our 
reviewer says that a Group 2 power wheelchair is not considered medically reasonable and necessary in this 
case. Records do not document that this patient has a personal mobility deficit that impairs participation in 
mobility related activities of daily living such as toileting, feeding, grooming and bathing in customary 
locations within the home or that his mobility deficit cannot be helped by the use of a walker, cane or manual 
wheelchair or that the patient can safely operate a power mobility device. Records report no mobility 
impairment that meets Medicare criteria for a group 2 power wheelchair. Our physician reviewer found that the 
enrollee's condition does not meet Medicare criteria for a Group 2 power wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Group 2 power wheelchair have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Group 2 power wheelchair for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cone beam imaging (D0383), unspecified adjunctive 
procedure (D9999), and the interpretation of a diagnostic image (D0391) provided on October 28, 2021. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says these 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. Therefore, we decided that the Plan does not have to pay for cone beam imaging (D0383), 
unspecified adjunctive procedure (D9999), and the interpretation of a diagnostic image (D0391) provided on 
October 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder Detect test (0012M) provided June 25, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that the appeal is in regards to the refund request 
dated January 20, 2022. Please review your records and review this appeal appropriately. The Plan denied your 
request. The Plan says they have determined that the claims referenced on the enclosed chart were overpaid. 
 
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 pay for the laboratory service. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found current available studies have not sufficiently supported the clinical use of the 
CxBladder Detect test specifically. There is a lack of high quality evidence supporting this test leading to 
overall improved outcomes. The NCCN 2019 guidelines for bladder cancer surveillance considers CxBladder 
Detect and similar molecular testing as tumor markers have better sensitivity but lower specificity compared to 
urinary cytology and considers the CxBladder Detect category 2B as evidence does not clearly show whether 
or not this test adds additional information that is useful for detection and management. Therefore, this request 
for CxBladder Detect will be considered not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for the Cxbladder Detect test (0012M) provided June 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the portable oxygen concentrator (E1392) purchased 
February 22, 2022. 
 
You asked the Plan to pay for the oxygen equipment. You say that you were unaware that a prior authorization 
was required. The durable medical equipment company sold you the portable oxygen concentrator out of 
pocket and you are requesting reimbursement. The Plan denied your request. The Plan says Medicare does not 
cover for the purchase of durable medical equipment. 
 
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet 
the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would 
benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify 
for oxygen solely based on blood gas studies obtained during sleep.   
 
We looked at this the file and Medicare rules. Medicare does not cover for the purchase of durable medical 
equipment. Oxygen equipment requires a prior authorization and is rented for 36 months. Based on this 
information, we decided that Medicare rules for coverage of the oxygen equipment have not been met. 
Therefore, we decided that the Plan does not have to pay for the portable oxygen concentrator (E1392) 
purchased February 22, 2022.