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

 
We decided that the Plan does not have to pay for an office visit provided on January 6, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and it was 
determined these services were not urgent or emergent. 
 
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 January 6, 2022 by an 
out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lupron depot (J1792). 
 
You asked the Plan to pre-approve Lupron depot. You say that the requested drug is medically necessary. The 
Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drug, Eligard. 
 
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 Lupron depot. Our reviewer says that 
the step therapy criteria have not been met. Our physician reviewer found the provided records do not indicate 
that the enrollee has tried and failed the plan's preferred step one alternative, Eligard. The record does not 
indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's preferred 
step one alternative. Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Lupron depot have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Lupron depot (J1792).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for brief emotional/behavioral assessment (96127 x3) provided 
on December 13, 2021. 
 
You asked the Plan to pay for brief emotional/behavioral assessment. The Plan denied your request. The Plan 
says the requested medical records were not received to indicate the units billed were performed for this 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of brief emotional/behavioral assessment 
(96127 x2) provided on December 13, 2021 have been met. Therefore, we decided that the Plan does not have 
to pay for brief emotional/behavioral assessment (96127 x2) provided on December 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vision field examination (92083) provided on October 
28, 2021. 
 
You asked the Plan to pay for the vision field examination. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare does not pay any provider or supplier other than the facility or 
hospital for services furnished to the beneficiary while an inpatient. 
 
We looked at the file and Medicare rules. In this case, the file shows the enrollee received these services during 
an inpatient hospitalization. Payment for these services were included in the facility payment. Therefore, we 
decided that the Plan does not have to pay for the vision field examination (92083) provided on October 28, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new patient office or other outpatient visit (99204) and 
manual therapy techniques (97140) provided on October 6, 2021. 
 
You asked the Plan to pay for new patient office or other outpatient visit (99204) and manual therapy 
techniques (97140). The Plan denied your request. The Plan says new patient office or other outpatient visit 
(99204) and manual therapy techniques (97140) are not covered by the Plan under any circumstance. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for a new patient office or other outpatient visit (99204) and manual therapy 
techniques (97140) provided  on October 6, 2021.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve prostate-specific membrane antigen (PSMA) positron emission 
tomography (PET) scan. 
 
You asked the Plan to pre-approve PSMA PET scan. You say that the requested service was denied using 
outdated guidelines. You also say that this service is medically necessary. The Plan denied your request. The 
Plan says that the requested service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 PSMA PET scan. Our reviewer says 
that the requested PSMA PET scan is considered medically reasonable and necessary in this case. Our 
physician reviewer found according to the Food and Drug Administration (FDA) label, PMSA PET scan is 
approved for suspected mets who are candidates for an initial prescription. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PSMA PET scan have been met. Therefore, we decided that the Plan has to pre-
approve prostate-specific membrane antigen (PSMA) positron emission tomography (PET) scan.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the autonomic nervous system function testing provided on 
June 15, 2021 by a non-network provider. 
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 rendered by a non-network provider without prior 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 the autonomic nervous system function testing 
provided on June 15, 2021 by a non-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 20, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like these services reprocessed 
based on the medical documentation. The Plan denied your request. The Plan says this claim has not been 
billed in accordance with Medicare coding regulations. 
 
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 the laboratory 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 provided on September 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate services. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
clinical effectiveness has not been demonstrated. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
Bone marrow aspirate during a lumbar fusion was requested. We asked our physician reviewer to carefully 
review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the 
request to pre-approve the requested services. Our physician reviewer found that bone marrow aspirate remains 
experimental. More research is needed to show safety and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided November 4, 2021. 
 
You asked the Plan to pay for the periodontal maintenance. You say that you do not understand why this 
service was covered previously but is not covered now. The Plan denied your request. The Plan says you have 
exceeded the frequency limit for this service. 
 
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. The Plan covers cleanings 
including periodontal cleanings twice per calendar year. 
 
We looked at file and Medicare rules. The Plan provided documentation showing that periodontal maintenance 
was previously covered on January 12, 2021, and April 16, 2021. Based on this information, we decided that 
the Plan's frequency limit for coverage of the periodontal maintenance has been exceeded. Therefore, we 
decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided November 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) provided 
by an in-network provider on January 26, 2022. 
 
You asked the Plan to pay for a comprehensive periodontal evaluation. You say that this should be covered. 
You say that this is very frustrating because this was preventative. The Plan denied your request. The Plan says 
D0180 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 a 
comprehensive periodontal evaluation (D0180) provided by an in-network provider on January 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional dental extractions. 
 
You asked the Plan to pre-approve the requested services. You say that your partial is no good anymore. The 
Plan denied your request. The Plan says the benefit has 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.  
 
We looked at the file, and Medicare rules. The file shows that 7 extraction procedures were requested. The Plan 
has agreed to pre-approve 3 extractions. Your plan only covers 3 extractions per calendar year. Based on this 
information, we decided that the Plan's rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional dental extractions.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a group 2 power wheelchair with single power option and related 
accessories (K0836, E2365, E1028, E1002, E2310). 
 
You asked the Plan to pre-approve a group 2 power wheelchair with single power option and related 
accessories. You say that this power wheelchair is medically necessary. The Plan denied your request. The Plan 
says that there is no medical need for power tilt seating system and, as a result, no medical need for a group 2 
power wheelchair with single power option. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  Medicare rules say that a 
group 2 power wheelchair with single power option is subject to the criteria listed 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 a group 2 power wheelchair with single 
power option and related accessories. Our reviewer says that the requested group 2 power wheelchair with 
single power option is medically necessary. Our physician reviewer found that per clinical documentation, the 
patient meets coverage criteria for group 2 power wheelchair with power tilt seating system. Seating evaluation 
was done and was shown that patient was unable to perform pressure relief with pressure relief cushion. It is 
also documented by provider that patient has multiple deteriorating wounds with decline in health thus would 
not expect history of decubitus ulcers however patient would still meet high risk criteria. Thus, the group 2 
power wheelchair with single power option and related accessories satisfy the criteria for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a group 2 power wheelchair with single power option and related accessories 
have been met. Therefore, we decided that the Plan has to pre-approve a group 2 power wheelchair with single 
power option and related accessories (K0836, E2365, E1028, E1002, E2310).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stance control for prosthesis (L5845). 
 
You asked the Plan to pre-approve stance control for prosthesis. You say that this prosthetic equipment is 
medically necessary. The Plan denied your request. The Plan says this device is included in the prosthetic 
equipment that was approved for coverage. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
We looked at the file and Medicare rules. The requested stance system is included in the approved prosthesis. 
The requested stance system cannot be approved separately. Based on this information, we decided that 
Medicare rules for coverage of stance control for prosthesis have not been met. Therefore, we decided that the 
Plan does not have to pre-approve stance control for prosthesis (L5845).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan of the head (70450). 
 
You asked the Plan to pre-approve a CT scan of the head. You say that this imaging service is medically 
necessary. The Plan denied your request. The Plan says that the medical records do not support the need for 
imaging in this case. 
 
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 a CT scan of the head. Our reviewer 
says that the requested imaging service is medically reasonable and necessary. Our physician reviewer found in 
this case the member is undergoing evaluation for memory problems. An imaging study is generally performed 
in the initial evaluation of cognitive impairment to rule out a structural etiology for the memory issues. In such 
a context, the requested service would be medically necessary as defined by Medicare. 
 
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 CT scan of the head have been met. Therefore, we decided that the Plan has to 
pre-approve a computed tomography (CT) scan of the head (70450).  
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Introduction of needle or intracatheter (36000) provided 
on November 13, 2021. 
 
You asked the Plan to pay for code 36000. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 We find that CPT code 36000 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 36000 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of code 36000 have not been met. Therefore, we decided that the Plan does not have to pay for the Introduction 
of needle or intracatheter (36000) provided on November 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse additionally for the dental services (D2392, D2330, 
D2331, and D5110) provided on April 19, 2021, and July 14, 2021. 
 
You asked the Plan to reimburse additionally for dental codes D2392, D2330, D2331, and D5110. You say that 
you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says they 
will not cover this amount because you have already received the maximum reimbursement amount of 
coverage allowed for 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. 
We looked at the file and the Plan's contract. The Plan's contract clearly says that they will pay up to $1000 
every year for non-Medicare covered preventive and comprehensive dental services combined. The file shows 
that the Plan reimbursed to you on May 18, 2021, a check for $259.50 and on September 30, 2021 a check for 
$740.50, totaling $1000. You are responsible for any amount above the $1000 dental coverage limit. Therefore, 
we decided that the Plan does not have to reimburse additionally for the dental services (D2392, D2330, 
D2331, and D5110) provided on April 19, 2021, and July 14, 2021.  
 
Your complaint about the Plan providing the incorrect information to you is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implant/abutment supported removable denture for 
edentulous arch (D6111). 
 
You asked the Plan to pre-approve the implant/abutment supported removable denture for edentulous arch. You 
say that this dental care is medically necessary. The Plan denied your request. The Plan says the benefit limit 
for the requested dental procedure has 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. One of the following dental 
services will be covered every five years:  D5120, D5212, D5214, D6111, or D6113 
 
We looked at the file and Medicare rules. In this case, the enrollees record confirms that they previously 
received a complete mandibular denture (D5120) in November 2021. Based on this information, we decided 
that the Plan's rules for coverage of the implant/abutment supported removable denture for edentulous arch 
have not been met. Therefore, we decided that the Plan does not have to pre-approve the implant/abutment 
supported removable denture for edentulous arch (D6111).