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

 
We decided that the Plan does not have to pay for lab testing provided on October 25, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says if the enrollee needs Medicare-covered medical care and a network provider is 
unable to provide this care, the enrollee may be able to get care from an out-of-network provider. Our plan 
must confirm there is not a network provider available and contact the plan to request authorization for the 
enrollee to obtain services from an out-of-network provider. If approved, the out-of-network provider will be 
issued an authorization to provide the service(s). 
 
 
 
 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 lab testing provided on October 25, 2021, 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 pneumatic compression device (E0652, E0667).  
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no documentation of a trial of at least four weeks of regular, daily, multiple-hour 
home usage of the E0650 or E0651. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the provided records do not document that the enrollee has lymphedema of the chest, trunk or 
abdomen; the records only document lower extremity edema. As there is no documentation that the enrollee 
has lymphedema of the chest, trunk or abdomen and there is no documentation of trial and failure of four 
weeks of a standard pump, it cannot be said that the enrollee has unique characteristics that would indicate the 
segmented pump over a standard pump. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a pneumatic compression device (E0652, E0667).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for dates of service April 1, 
2022, to April 30, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that the services at issue were billed correctly. 
The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for dates of service April 1, 2022, to April 30, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomographic angiography (CTA), of the chest 
(non-coronary), with contrast material(s), including non-contrast images, if performed, and image 
postprocessing (71275) and computed tomographic angiography (CTA), of the abdomen, with contrast 
material(s), including non-contrast images, if performed, and image postprocessing (74175). 
 
You asked the Plan to pre-approve these services. You say that the requested services are medically necessary 
for the enrollee. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 these services. Our reviewer says that 
the requested services are not medically necessary. Our physician reviewer found that the enrollee has had a 
negative electromyography (EMG) and the total spine magnetic resonance imaging (MRI) has shown no 
significant abnormality. The rationale for the requested CTA of the chest, abdomen, and pelvis is not addressed 
anywhere in the submitted records. Absent a discussion concerning the need for the requested CTA studies, the 
medical necessity is also not established. 
 
 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 computed tomographic angiography (CTA), of the chest (non-coronary), with contrast 
material(s), including non-contrast images, if performed, and image postprocessing (71275) and computed 
tomographic angiography (CTA), of the abdomen, with contrast material(s), including non-contrast images, if 
performed, and image postprocessing (74175).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visit to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve office visit. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says the enrollee must get their care from a network provider. In most cases, care 
the enrollee receives from an out-of-network provider (a provider who is not part of our plans network) will 
not be covered and youll be responsible for the cost. 
 
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 
office visit 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 pre-approve continued care with an out-of-network tertiary level 
hematologist/oncologist. 
 You asked the Plan to pre-approve continued care with an out-of-network tertiary level 
hematologist/oncologist. You say that continued care with the out-of-network tertiary level 
hematologist/oncologist is medically necessary. The Plan denied your request. The Plan says continued care 
with the out-of-network tertiary level hematologist/oncologist is not medically necessary as the enrollee can 
transition to an in-network non-tertiary level oncologist. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 continued care with an out-of-network 
tertiary level hematologist/oncologist. Our reviewer says that continued care with the out-of-network tertiary 
level hematologist/oncologist is not medically necessary. Our physician reviewer found the enrollee is not 
currently receiving any active treatment and/or medical management of her condition that makes it medically 
necessary for her to continue care with the out-of-network tertiary level hematology/oncology provider. There 
is not anything unique about the enrollee's condition that would make it medically necessary for her to continue 
care with the out-of-network specialist. The Plan has shown that they have in-network oncology specialists 
who have the qualification and expertise necessary to meet the current medical Standards of Care required for 
treatment of the enrollees condition. This enrollee's medical management and/or follow-up care can be safely 
transitioned to an in-network non-tertiary level oncology specialist 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 continued care with an out-of-network tertiary level hematologist/oncologist 
have not been met. Therefore, we decided that the Plan does not have to pre-approve continued care with an 
out-of-network tertiary level hematologist/oncologist.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services and x-ray services 
provided from June 24, 2022, to June 28, 2022. 
 
You asked the Plan to waive the copayment for laboratory services and x-ray services. You say that you believe 
that the services should be part of your annual physical. 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 $10 
copayment for outpatient diagnostic tests/Medicare-covered laboratory tests that are not FIT tests, outpatient 
diagnostic tests/Medicare-covered X-rays.  
 
You have been asked to pay a $10 copayment for laboratory services and a $10 copayment for x-ray services. 
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 laboratory services and x-ray services provided from June 
24, 2022, to June 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on June 21, 
2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that this was a biopsy not surgery 
so you shouldnt be charged this. 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 $100 
copayment for Outpatient surgery. 
 
You have been asked to pay a $100 copayment for outpatient surgery. This item/service falls within the 
Outpatient surgery 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 outpatient surgery 
provided on June 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injections to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve injections. You say that you are in pain and need this service. 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 out-of-network (OON) provider or facility, and this is not an emergency. There are 
providers who can perform these services within your network. 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 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 
injections 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 pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that you are not satisfied and happy with the service 
provided by the urologist in the Plan's network. You also say the urologist provided by the Plan does not 
provide good service and does not pay attention to the problems of patients. The Plan denied your request. The 
Plan says you must receive your care from a 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 
an office visit 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 pre-approve percutaneous intradiscal electrothermal annuloplasty, 
single level (22526), and percutaneous intradiscal electrothermal annuloplasty, 1 or more additional level 
(22527). 
 
You asked the Plan to pre-approve thermal intradiscal procedures (TIPs). You say that the requested services 
are safe and effective. You also say that the services are medically necessary. The Plan denied your request. 
The Plan says the requested services are not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that thermal intradiscal procedures (TIPs) are not 
reasonable and necessary for the treatment of low back pain. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of thermal intradiscal procedures (TIPs) have not been met. Therefore, we decided that the Plan does 
not have to pre-approve percutaneous intradiscal electrothermal annuloplasty, single level (22526), and 
percutaneous intradiscal electrothermal annuloplasty, 1 or more additional level (22527).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prosthesis with an advanced foot and microprocessor 
knee and foot. 
 
You asked the Plan to pre-approve the items. You say that this is medically necessary. The Plan denied your 
request. The Plan says this request for a prosthesis with advanced foot and microprocessor knee and foot does 
not meet Medicare criteria as reasonable and 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 items. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this request exceeds the enrollee's medical needs. The documentation does not support that the 
patient's functional needs cannot be met with a mechanical knee. Furthermore, the physician medical progress 
note documentation does not support the need for a K3 level knee. The patient ambulates mostly indoors and at 
times with a cane.  Furthermore, a review of the Linx system indicates it has convenience features which are 
not medically necessary per Medicare criteria such as a covered and magnetic charging point and a 
programming application for Android and iOS. The requested Linx system exceeds the patient's medical needs 
and is 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 items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a prosthesis with an advanced foot and microprocessor knee and foot.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral evaluation (D0120), prophylaxis 
(D1110), bitewing x-rays (D0274), and a periapical x-ray (D0220) provided on March 9, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you were told these services were 
covered. The Plan denied your request. The Plan says you are responsible for any charged amount above the 
Plans cost-sharing amount when your services are received from an out-of-network provider. 
 
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. 
 
You have been asked to pay a total of $120, which is the difference between the out-of-network providers 
charges and the Plans payment. 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 pay more for a periodic oral 
evaluation (D0120), prophylaxis (D1110), bitewing x-rays (D0274), and a periapical x-ray (D0220) provided 
on March 9, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the core buildup (D2950) for tooth #7 provided on May 17, 2022. 
 
You asked the Plan to pay for the dental service. You say that the core buildup was necessary to support the 
crown on your tooth. The Plan denied your request. The Plan says that the denial of payment for this service is 
correct, because the core buildup was not necessary to retain a crown on the tooth. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the dental 
service when the services are medically necessary and reasonable. 
 
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 dental service. Our reviewer says that the 
core buildup (D2950) for tooth #7 is medically necessary. Our physician reviewer found that the 
documentation indicates that tooth #7 has a large composite restoration with recurrent caries. Removal of this 
restoration would render the remaining tooth structure weak. A core buildup to support and retain a crown 
restoration is medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental service have been met. Therefore, we decided that the Plan has to pay 
for the core buildup (D2950) for tooth #7 provided on May 17, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for suture of recent small wounds (D7910) provided by a 
participating provider on August 5, 2022. 
 
You asked the Plan to pay for suture of recent small wounds. You say that the services were pre-approved. The 
Plan denied your request. The Plan says the rendered dental 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 suture of 
recent small wounds (D7910) provided by a participating provider on August 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the shipping and handling (S9999) provided on 
May 10, 2022. 
 
You asked the Plan to reimburse you for the shipping and handling. You say that you paid out of pocket for the 
services. You say that you were advised the check was sent to the provider's office. You say that you would be 
reimbursed for everything except for the $35 copayment. You also say that you should be reimbursed. The Plan 
denied your request. The Plan says the claim processed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the shipping and handling have not been met. Therefore, we decided that the Plan does not have to 
reimburse you for the shipping and handling (S9999) provided on May 10, 2022.