Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on June 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration for 
payment. 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 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 the dental 
services on June 7, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Humulin R. 
 
You asked the Plan to pre-approve Humulin R. You say that this request is for a continuation of medication. 
The Plan denied your request. The Plan says the requested service is not covered by Medicare or the 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 Humulin R.  
 
Benefits for Humulin R 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vacuum socket system (L5781). 
 
You asked the Plan to pre-approve a vacuum socket system. You say that the request is justified given the 
failed use of a standard prosthetic. It is medically reasonable and responsible to provide a system that will work 
with the patient's anatomy to provide skin protection and accommodate fluctuations in volume to facilitate 
ambulatory activities. The Plan denied your request. The Plan says the use of vacuum pumps for residual limb 
volume management and moisture evacuation systems among amputees is unproven and not medically 
necessary due to insufficient evidence of safety and/or efficacy. 
 
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 vacuum socket system. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the vacuum pump, residual limb volume management and moisture evacuation 
system exceeds the enrollees medical needs and is not proven superior to a standard socket therefore does not 
meet Medicare medically necessary criteria as Medicare does not pay for any items or services that are not 
reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a 
malformed body member. The literature reviewed indicates that further research is needed with clinical trials 
that recruit larger sample sizes and report long-term outcome data for the requested elevated vacuum 
suspension system. 
 
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 vacuum socket system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a vacuum socket system (L5781).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental crown (D2751) 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. 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 benefit for the requested item or service was exhausted on date of service March 21, 2022. 
Therefore, we decided that the Plan does not have to pre-approve a dental crown (D2751)
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 72170 billed for date of service March 14, 
2022. 
 
You asked the Plan to pay for procedure code 72170. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 72170 is bundled into payment for code 73502.  
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 72170 
is a column II code to column I code 73502. 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 procedure code 72170 billed for date of service March 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction service (92015) provided on April 12, 2022. 
 You asked the Plan to pay for the vision care. You say that the service was billed for a medical condition and 
not a routine visit. You also say that this should be covered because you also had a routine eye exam done. The 
Plan denied your request. The Plan says refraction service is not covered by Medicare. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. 
 
We looked at the file and the Plan's rules. Original Medicare doesnt cover routine eye exams (eye refractions). 
Based on this information, we decided that the Plan's rules for coverage of the vision care have not been met. 
The record shows that the vision exam was related to nonexudative age-related macular degeneration, bilateral, 
early dry stage, thus not a routine vision exam. Therefore, we decided that the Plan does not have to pay for the 
refraction service (92015) provided on April 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan of the 
thorax for lung cancer screening (71271). 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that you are requesting a reconsideration 
of the Plan's denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
coverage of the requested service. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
  
We reviewed the file and the Medicare rules. We find that the enrollee does not meet criteria for coverage of a 
LDCT scan. Specifically, the enrollee must be a current smoker or former smoker who quit within the last 15 
years. Additionally, the enrollee must have a tobacco smoking history of at least 30 pack-years. The record 
shows that the enrollee quit smoking in 1977, more than fifteen years ago and has a 5 pack-year smoking 
history. In order to be eligible for coverage of the requested service, the enrollee must meet all criteria. 
Therefore, we decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) 
scan of the thorax for lung cancer screening (71271).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diabetic shoes and inserts to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve diabetic shoes and inserts. You say that you are requesting an appeal 
because your prior authorization was denied. The Plan denied your request. The Plan says care that the enrollee 
receive from out-of-network provider will not be covered unless the care meets one of the three exceptions 
described in Section 1.2 of this chapter. 
 
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 
diabetic shoes and inserts 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 waive the copayment for specialist office visit provided on May 13, 
2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that you only spoke with the 
nurse and never saw the doctor. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 
copayment for Visit or consultation in an outpatient location with a specialist.. 
 
You have been asked to pay a $25 copayment for specialist office visit. This item/service falls within the Visit 
or consultation in an outpatient location with a specialist. 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 specialist office visit provided on May 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) and core buildup (D2950). 
 
You asked the Plan to pre-approve the dental services. 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 benefit for the requested item or service was exhausted on date of service April 13, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) and core buildup (D2950).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychiatry visit provided on April 13, 2022, and May 26, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a psychiatry visit. You say that this should be covered, you could not leave this 
beneficiary in a distressed state. The Plan denied your request. The Plan says there was no preauthorization by 
a primary care provider (this is different than a referral) for an OON provider or facility, and this was not an 
emergency. Therefore, the decision is upheld. 
 
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 a psychiatry visit provided on April 13, 2022, and 
May 26, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for podiatry service provided on March 17, 
2022. 
 
You asked the Plan to waive the copayment for podiatry service. You say that someone from the office told 
you that there is no copayment. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $30 
copayment for Medicare-covered visit.  
 
You have been asked to pay $30 copayment for podiatry service. This item/service falls within the Medicare-
covered visit 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 podiatry service provided 
on March 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the osteogenesis stimulator, electrical, non-invasive, 
spinal applications (E0748). 
 
You asked the Plan to pre-approve the osteogenesis stimulator. You say that your doctor requested an 
osteogenesis stimulator after your back surgery. The Plan denied your request. The Plan says under Medicare 
guidelines, this request is not 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 pre-approve the osteogenesis stimulator. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee had a 2-level lumbar fusion and not enough time has passed 
since the surgery to establish the diagnosis of nonunion. 
 
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 osteogenesis stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the osteogenesis stimulator, electrical, non-invasive, spinal applications 
(E0748).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power wheelchair (PWC). 
 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. Medicare rules say that a Group 2 PWC is covered when specific criteria 
are met. 
 
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 records show that you were 
approved for a Group 3 PWC in January of 2022. There is no documentation of a specialty evaluation 
performed by a licensed/certified medical professional for the requested Group 2 PWC. The Group 3 PWC was 
recommended for your needs. The Group 2 PWC is not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Group 2 power wheelchair (PWC).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 28, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that it was medically necessary to treat the enrollee. The 
Plan denied your request. The Plan says the rendering provider is an OON provider and there was no approved 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on June 28, 2022, by an 
out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for cataract surgery provided on May 20, 
2022. 
 
You asked the Plan to waive the coinsurance for cataract surgery. You say that you thought all cataract 
procedures were covered in full. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 18% 
coinsurance for Vision services in a specialists office. 
 
You have been asked to pay 18% coinsurance for cataract surgery. This item/service falls within the Vision 
services in a specialists office 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 cataract 
surgery provided on May 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care provided on June 27, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for wound care. You say that the physician provided care in good will without 
requesting an authorization to avoid delay in care, which could result in medical complications. The Plan 
denied your request. The Plan says in most situations, our plan must give the enrollee approval in advance 
before the enrollee can use other providers in the plans network, such as specialists, hospitals, skilled nursing 
facilities, or home health care agencies. This is called giving the enrollee a referral. For more information 
about this, see Section 2.3 of this chapter. 
 
 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for wound care provided on June 27, 2022, by an out-
of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intravenous infusion or subcutaneous injection (M0244) 
provided on January 7, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the intravenous infusion or subcutaneous injection. You say that at the time this 
claim was denied, according to state orders, patients were able to self-refer for lifesaving COVID-19 
treatments. The Plan denied your request. The Plan says this service was rendered by a non-network provider, 
the enrollee self-directed for care, and their primary care provider did not refer them for services. The Plan also 
says that no medical necessity for an OON provider, such as an urgent or emergency situation, has been 
documented.  
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 the intravenous infusion or subcutaneous injection 
(M0244) provided on January 7, 2022 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on 
June 2, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that the services should be covered under the 
facility authorization. You also say that the service was provided in good faith. The Plan denied your request. 
The Plan says prior authorization was not obtained. 
 
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 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 the subsequent nursing facility care (99308) provided on June 2, 
2022, by an out-of-network (OON) provider.