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

 
We decided that the Plan does not have to pre-approve Trelegy Aer Ellipta. 
 
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 self-administered drugs are not covered. 
 
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 Trelegy Aer Ellipta.  
 
Benefits for these services 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 waive the coinsurance for portable oxygen equipment provided on 
October 23, 2021. 
 
You asked the Plan to waive the coinsurance for the portable oxygen equipment. You say that you were not 
informed of any monthly costs for the equipment. The Plan denied your request. The Plan says the correct 
coinsurance was applied. 
 
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 20% coinsurance for durable medical equipment (DME) items, including oxygen equipment.  
 
Item Allowed Amount 20% Coinsurance 
Portable Oxygen Machine $22.30 $4.46 
Oxygen Concentrator $123.75 $24.75 
Total:  $29.21 
 
You have been asked to pay a total of $29.21, which is 20% of the allowed amount for the portable oxygen 
equipment. The portable oxygen equipment falls within the Durable Medical Equipment (DME) and Related 
Supplies 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 portable oxygen 
equipment provided on October 23, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme. 
 
You asked the Plan to pre-approve Feraheme. You say that the requested Feraheme is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail Infed and Venofer first. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 Feraheme. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found based on the medical records 
provided there is no indication that the enrollee has tried and failed the required drug(s). Based on the medical 
records provided and the Medicare-approved major drug compendia there is no indication that the plan's 
required drug(s) would likely be less effective and/or likely have adverse effects 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 Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mass spectrometry and tandem mass spectrometry (MS, 
MS/MS), analyte not elsewhere specified (83789) provided February 13, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that please review the attached laboratory 
results. The Plan denied your request. The Plan says the records do not support the billed service. 
 
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, the CPT Code Manual definition of code 83789 is mass spectrometry and tandem mass 
spectrometry (MS, MS/MS), analyte not elsewhere specified.  
We find that CPT code 83789 is not supported in the medical record. Specifically, this code is not separately 
reimbursed when billed for specimen validity testing on specimens used for drug testing. The Plan made 
multiple attempts to contact the provider for additional information. Based on this information, we decided that 
Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for mass spectrometry and tandem mass spectrometry (MS, MS/MS), analyte not 
elsewhere specified (83789) provided February 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a stair glide provided on November 17, 2021. 
 
You asked the Plan to pay for a stair glide. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pay for a stair glide provided on November 17, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on March 11, 2022.

You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says there is no authorization to see an out-of-network provider.

The Plan must follow Medicare rules. Medicare rules say that a Licensed Professional Counselor is not eligible to participate in the Medicare program. 

We looked at the file and Medicare rules. The provider at issue in this case is a Licensed Professional Counselor. Medicare says that a Licensed Professional Counselor is not eligible to participate in the Medicare program. Therefore, we decided that the Plan does not have to pay for psychotherapy services provided on March 11, 2022.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for CPT 66984. We decided that the Plan does not have to pay for V2787.  
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan says that this was not 
reported correctly. 
 
 
 
 We decided that the Plan has to pay for 66984.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The plan has not given a valid reason for why CPT 66984 is still denied in this case.  Based on this 
information, we decided that Medicare rules for coverage of the services have been met. Therefore, we decided 
that the Plan has to pay for 66984.  
 
We also decided that the Plan does not have to pay for V2787. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The denied code - V2787 - has a status indicator of E1. It is not paid by Medicare on outpatient claims. 
Additionally, the Medically Unlikely Edits (MUE) for this code is 0, which means that no units of this code are 
appropriate for billing. Based on this information, we decided that Medicare rules for coverage of V2787 have 
not been met. Therefore, we decided that the Plan does not have to pay for V2787. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the emergency department services (99285-25) provided on February 9, 
2022. 
 
You asked the Plan to pay for the emergency department services. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says that this is not a covered 
benefit because the records show that this visit code is being charged twice by the same practitioner on one 
day. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
We looked at the file and Medicare rules. We find that the file does not include sufficient evidence to support 
the Plans argument that the provider has billed the same evaluation and management code twice. Specifically, 
there is no other claim submitted which document the provider billing evaluation and management services 
twice for the same problem. Based on this information, we decided that Medicare rules for coverage of the 
emergency department services have been met. Therefore, we decided that the Plan has to pay for the 
emergency department services (99285-25) provided on February 9, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat epidural steroid injection (ESI) services. 
 
You asked the Plan to pre-approve repeat ESI services. You say that you are in pain and the records provided 
support the need for the requested ESI services. The Plan denied your request. The Plan says the clinical 
information received does not show that the requested services are medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that repeat ESIs are covered for certain clinical 
indications and when 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 repeat ESI services. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found the enrollee had a previous 
epidural steroid injection on July 19, 2022. The medical records do not discuss whether the injection was 
effective and do not discuss the rationale for a repeat request. The review has determined that the records do 
not demonstrate that the first ESI performed directly and significantly provided improvement of the condition 
being treated. The records do not demonstrate that the first ESI produced at least 50% of sustained 
improvement in pain relief and/or improvement in function measured from baseline using the same scale for at 
least 3 months or that the enrollee failed to respond well to the initial ESI, and this repeat ESI would be done after 14 days using a different approach, level, and/or medication. The medical necessity for a second ESI is 
not documented in the medical record. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of repeat ESI services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve repeat epidural steroid injection (ESI) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a shower chair provided on October 1, 2021. 
 
You asked the Plan to pay for a shower chair. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pay for a shower chair provided on October 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for fixed partial denture repair necessitated by restorative 
material failure (D6980) on January 11, 2022. 
 
You asked the Plan to pay for fixed partial denture repair necessitated by restorative material failure (D6980). 
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 fixed 
partial denture repair necessitated by restorative material failure (D6980) on January 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for recement crown (D2920) provided on March 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not aware you had to see a plan 
provider. The Plan denied your request. The Plan says the dental services were not received from your assigned  
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 did not receive the requested dental services from your assigned provider. Though the 
Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered 
under this benefit unless received from your assigned provider. Therefore, we decided that the Plan does not 
have to pay for recement crown (D2920) provided on March 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you take Lasix and need incontinence 
products because sometimes you have accidents. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that the enrollee has flat feet, and arthritis in both 
feet & legs for over 35 years. The situation has gotten so bad right now that she is unable to walk and is 
confined to an assisted care living facility. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on March 31, 2022. 
 
You asked the Plan to pay for the dental services. You say that the provider was unable to get a hold of any 
representative to confirm benefits. 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 dental services provided on March 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for portable oxygen equipment provided on 
September 23, 2021. 
 
You asked the Plan to waive the coinsurance for the portable oxygen equipment. You say that you were not 
informed of any monthly costs for the equipment. The Plan denied your request. The Plan says the correct 
coinsurance was applied. 
 
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 20% coinsurance for durable medical equipment (DME) items, including oxygen equipment.  
 
Item Allowed Amount 20% Coinsurance 
Oxygen Concentrator $123.75 $24.75 
Portable Oxygen Machine $22.30 $4.46 
Total:  $29.21 
 
You have been asked to pay a total of $29.21, which is 20% of the allowed amount for the portable oxygen 
equipment. The portable oxygen equipment falls within the Durable Medical Equipment (DME) and Related 
Supplies 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 portable oxygen 
equipment provided on September 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a problem focused limited oral evaluation (D0140) on April 
19, 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 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 3, 2022. 
Therefore, we decided that the Plan does not have to pay for a problem focused limited oral evaluation (D0140) 
on April 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (83789) provided on February 10, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this code cannot be separately reimbursed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Medicare rules say that specimen validity testing is not covered separately. 
  
The services at issue in this case are for the purpose of specimen validity testing. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided 
that the Plan does not have to pay for the laboratory services (83789) provided on February 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300) and attendant 
control (E2331). 
 
You asked the Plan to pre-approve a power seat elevation feature and attendant control. You say that you 
would like these accessories covered in addition to the previously approved power wheelchair equipment. The 
Plan denied your request. The Plan says these items are not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) and 
power standing feature (E2301) are non-covered because they are not primarily medical in nature. Medicare 
rules say that if an attendant control (E2331) is provided in addition to a beneficiary-operated drive control 
system, it will be denied as non-covered. 
 We looked at the file and Medicare rules. In this case, the power seat elevation feature is statutorily non-
covered by Medicare. In addition, the enrollee has been previously approved for a beneficiary-operated drive 
control system. Therefore, the attendant control will be denied as non-covered. Based on this information, we 
decided that Medicare rules for coverage of a power seat elevation feature and attendant control have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature (E2300) 
and attendant control (E2331).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Ossur Balance OFM2 knee. 
 
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 billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
The file shows that requested procedure code L5845 is not valid for the requested Ossur Balance OFM2 knee. 
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 an Ossur Balance OFM2 knee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for maxillary partial denture - cast metal framework with resin 
denture bases (D5213). 
 
You asked the Plan to pay for the partial denture. You say that you picked the cheapest way to have your teeth 
replaced with the partial denture. The Plan denied your request. The Plan says this service is not a covered 
benefit under your plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for maxillary 
partial denture - cast metal framework with resin denture bases (D5213).