Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for massage therapy visits provided from May 3, 2021, through 
June 28, 2021. 
 
You asked the Plan to pay for the massage therapy visits. You say that this therapy is a specialty credential 
which this provider has, and you were referred by your doctor. You say that you need and deserve more paid 
treatments. The Plan denied your request. The Plan says only six massage therapy visits are covered per 
calendar year. 
 
  Medicare does not cover massage therapy. However, the Plan offers a therapeutic massage benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
 
Though the Plan offers a massage benefit in excess of Medicare coverage, you have a maximum benefit of 6 
therapeutic massage visits per calendar year. The Plan paid for 6 therapeutic massage visits provided from 
January 10, 2021, through April 26, 2021, which exhausted your benefit. Therefore, we decided that the Plan 
does not have to pay for massage therapy visits provided from May 3, 2021, through June 28, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for weekly methadone clinic visits provided 
from October 28, 2021, to December 23, 2021. 
 
You asked the Plan to waive the copayments for methadone clinic visits. You say that you have gone to this 
clinic for seven years and have never been billed a copayment before. You also say that you had an agreement 
with the provider that because you are over 65 years old the clinic would not be charging you. 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 a $25 
copayment for each outpatient substance abuse visit.  
 You have been asked to pay a total of $225, which is a $25 copayment for nine methadone clinic visits from 
October 28, 2021, to December 23, 2021 ($25 copayment x 9 visits = $225). Methadone clinic visits falls 
within the Outpatient Substance Abuse 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 
copayments for weekly methadone clinic visits provided from October 28, 2021, to December 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intradialytic parenteral nutrition to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve intradialytic parenteral nutrition. You say that it is medically necessary for 
the enrollee to receive this treatment from you. The Plan denied your request. The Plan says there are in-
network providers that they would approve for this treatment. 
 
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 
intradialytic parenteral nutrition to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the flex-walk system (L5981). 
 
You asked the Plan to pre-approve the flex-walk system. You say that this device is medically reasonable and 
necessary. The Plan denied your request. The Plan says the enrollee appears to be no longer a K3 ambulator, 
and the subsequent K3 foot cannot be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that the flex-walk system is covered for enrollees 
whose functional level is 3 or above. 
 
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 for the flex-walk system. Our reviewer says that the 
requested item is not medically reasonable and necessary. Our physician reviewer found that the Plan has 
authorized a replacement part including a foot and ankle. The documentation provided by the provider does not 
support that the member is a K3 ambulator. He requires a cane for ambulation in the community and appears to 
be a basic community ambulator. The requested K3 foot and ankle system 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 for the flex-walk system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the flex-walk system (L5981).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services (97110) and additional supplies 
and materials (99072) provided on September 28, 2021. 
 
You asked the Plan to pay for physical therapy services (97110) and additional supplies and materials (99072). 
You say that plans are required to pay non-contract providers at the preferred provider rate when services are 
not available from preferred providers in the service area. You say that the in-network benefits should be 
honored, and the claim processed for payment. The Plan denied your request. The Plan says the physical 
therapy services are not supported, and the additional supplies are denied as bundled services are not separately 
payable. 
 
The Plan must follow Medicare rules say that the services of a PTA shall not be billed as services incident to a 
physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist. 
Medicare rules say that procedures should be reported with the Current Procedural Terminology (CPT) code 
that describes the services performed. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of physical therapy services (97110) and additional supplies and materials (99072) have not been met. 
Specifically, a nurse practitioner is not able to bill for the services of an PTA because the nurse practitioner is 
not a therapist. In addition, CPT code 99072 has a status indicator of B. This means that CPT code 99072 is 
considered bundled and not separately payable. Therefore, we decided that the Plan does not have to pay for 
physical therapy services (97110) and additional supplies and materials (99072) provided on September 28, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99205) provided October 4, 2021. 
 
You asked the Plan to pay for the office visit. You say that you feel this should be covered as this bill was for 
extensive Alzheimers assessment to determine further steps in medication and health management. The Plan 
denied your request. The Plan says if you go to a provider who is not eligible to participate in Medicare, you 
will be responsible for the full cost of the services you receive. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
outpatient office visit (99205) provided October 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup (D2950), and crown (D2740), purchased on 
November 19, 2021. 
 
You asked the Plan to pay for the routine dental services. You say that the services should be covered. The Plan 
denied your request. The Plan says core buildup is not a covered benefit and you have met your allowed 
maximum benefit for supplemental dental services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core 
buildup (D2950), and crown (D2740), purchased on November 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient office visit (99213) Acupuncture, initial 15 
minutes (97810) acupuncture, each additional 15 minutes (97811) provided December 2, 2021. 
 
You asked the Plan to pay for the acupuncture office visit. You say that when you were given 10 visits you had 
already gone to 4 or 5 visits so you should still have some visits left. The Plan denied your request. The Plan 
says the benefits have been exhausted. 
 The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the records show that this visit was the 11th visit. 
Therefore, the maximum benefit allowed has been met. Therefore, we decided that the Plan does not have to 
pay for outpatient office visit (99213) Acupuncture, initial 15 minutes (97810) acupuncture, each additional 15 
minutes (97811) provided December 2, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve speech therapy to be provided by an OON provider. 
 
You asked the Plan to pre-approve speech therapy. You say that the recommended in-network provider is too 
far away. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because this provider is out-of-network with the Plan and the enrollee can be treated at an in-network speech 
therapy facility. 
 
Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is 
considered accessible to an enrollee if contract providers are available within reasonable distance and travel 
time from the enrollees home. The plan contract says that enrollees must use contract providers.  
 
The provider is a non-contract provider. We were able to confirm that the Plan has contract providers located 
within reasonable distance and travel time from the enrollees home who can provide speech therapy. Under 
Medicare rules, this means that contract providers are accessible to the enrollee. Therefore, we decided that the 
Plan does not have to pre-approve speech therapy to be provided by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Humira pen. 
 
You asked the Plan to pre-approve Humira. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says this drug is not covered under the enrollee's medical benefit. 
 
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 Humira pen.  
 
Benefits for Humira 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee can safely receive the services he needs in another setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for a diabetic foot ulcer 
and had a below the knee amputation. The enrollees medical problems are stable. There are no complex 
nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has 
a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 
rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer 
found that the enrollee's condition does not meet Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on June 2, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on June 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the electronic connection (E2311), expandable 
controller (E2377), and harness (E2313). 
 
You asked the Plan to pre-approve the wheelchair accessories. You say that the items are medically necessary. 
The Plan denied your request. The Plan says the items are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that only medically necessary items are 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 for the wheelchair accessories. Our reviewer says that 
these items are not medically necessary. Our physician reviewer found that the member has use of his right 
upper extremity and can operate and control the power options using the switches that are included in the basic 
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 the wheelchair accessories have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the electronic connection (E2311), expandable controller (E2377), and 
harness (E2313).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the excision of a benign lesion (D7411) provided on 
December 14, 2021. 
 
You asked the Plan to pay for excision of a benign lesion. You say that this service was a necessary medical 
procedure and should be covered. The Plan denied your request. The Plan says this service is not covered by 
your dental 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 
excision of a benign lesion (D7411) provided on December 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiac risk assessment genetic screening testing (CPT 
code 81479) provided on September 8, 2021. 
 
You asked the Plan to pay for the screening testing. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The enrollee's provider did not order cardiovascular genetic testing. Per progress notes provided, the enrollee 
was seen on July 12, 2021, for a follow up. Per the laboratory staff, all hereditary genetic testing is provided to 
members via mail and returned to lab via mail. Therefore, POS 81 is also not applicable. Furthermore. the test 
at issue in this appeal, the screening testing, was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
cardiac risk assessment genetic screening testing (CPT code 81479) provided on September 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin based composite (D2391), provided on November 
10, 2021. 
 
You asked the Plan to pay for the resin based composite. You say that the item should be covered. The Plan 
denied your request. The Plan says you obtained this service out-of-network. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Specifically, you obtained this item out-of-network. Therefore, we 
decided that the Plan does not have to pay for the resin based composite (D2391), provided on November 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the specialist office visit. You say that you have a relationship with the out-
of-network provider from prior appointments and no relationship with the in-network provider. The Plan 
denied your request. The Plan says there is an established authorization with an in-network provider that 
provides the same service the enrollee is needing along with accepting new patients. Also, there is no issue 
with the continuity of care since it was over a year since the enrollee was seen by the out-of-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 
a specialist office visit to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis 
(D1110) provided on November 29, 2021. 
 
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you were never told 
that a cleaning comes out of your $1,000 dental allowance. You also say that if you had known, you would 
have waited until January. The Plan denied your request. The Plan says you met your $1,000 annual dental 
allowance prior to the denial of this claim. The Plan also says that the total cost of the services in the amount of 
$162 denied correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan offers a $1,000 combined 
allowance for supplemental preventive and comprehensive dental services every year. The contract says that 
you are responsible for any amount over and above the allowance amount. The record shows that you met the 
annual maximum benefit on May 25, 2021 and your annual maximum benefit has been exhausted. Therefore, 
we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis 
(D1110) provided on November 29, 2021.