Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve psychiatry appointments, in person, to be provided the 
requested provider. 
 
You asked the Plan to pre-approve psychiatry appointments, in person. You say that when scheduling the 
appointment, the provider's office was very clear that you needed an in-person appointment, but you received a 
notice with the instructions for a virtual visit. You say that you need in person appointments to accommodate 
your disability. The Plan denied your request. The Plan says you have been provided with a behavioral contract 
which outlines the expectation of your behavior while in clinic. However, you have yet to adhere to 
demonstrate behaviors that are suitable for an in-clinic appointment. The Plan has provided all medically 
necessary levels of care and appointment frequency. The Health Plan will continue to provide psychiatry visits 
by telehealth or by video appointments. 
 
The Plan must follow Medicare rules. Medicare rules say that a Marriage Family Therapist 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 Marriage Family Therapist. 
Medicare says that a Marriage Family Therapist is not eligible to participate in the Medicare program. 
Therefore, we decided that the Plan does not have to pre-approve psychiatry appointments, in person, to be 
provided by the requested provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0100). 
 
You asked the Plan to pre-approve additional trips. You say that you are blind. You say that you have no 
family support. You also say that you need transportation to your chemotherapy appointments. The Plan denied 
your request. The Plan says additional trips beyond the 20 one-way trips allowed are not covered. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 20 one-way trips per year.  
 
  
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips (A0100).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a venous introduction of needle or intracatheter (36000) and 
an ultrasound guidance for vascular access (76937) provided on November 26, 2021. 
 
You asked the Plan to pay for a venous introduction of needle or intracatheter and an ultrasound guidance for 
vascular access. You say that you have provided records to support the services billed. The Plan denied your 
request. The Plan says rules for payment have not been met. 
 
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. Furthermore, we have confirmed that code 76937 is an add-on code and 
has not been billed with an appropriate or payable primary procedure code. Based on this information, we 
decided that Medicare rules for coverage of a venous introduction of needle or intracatheter and an ultrasound 
guidance for vascular access have not been met. Therefore, we decided that the Plan does not have to pay for a 
venous introduction of needle or intracatheter (36000) and an ultrasound guidance for vascular access (76937) 
provided on November 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (d 81321, 81206, 81210, 81235, 81272, 
81275, 81276, 81292, 81301, 81311) provided September 30, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel constitutes a single procedural service, so 
one code must be submitted for the panel. 
 
We looked at the file and Medicare rules. Multiple unbundled codes were submitted for a single panel. Based 
on this information, we decided that Medicare rules for coverage of the genetic testing have not been met.  
 
 
 
 
 
 
  
 
Therefore, we decided that the Plan does not have to pay for genetic testing (d 81321, 81206, 81210, 81235, 
81272, 81275, 81276, 81292, 81301, 81311) provided September 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0100). 
 
You asked the Plan to pre-approve additional trips. You say that the enrollee does not have any resources to 
reach your treatment 3 times per week. You say that the municipality does not provided transportation to a 
dialysis patient. You also say that the enrollee does not have family support. The Plan denied your request. The 
Plan says additional trips exceeding the 24 one-way trips covered per year are not covered.  
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when 24 one-way.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional routine transportation trips (A0100).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 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 SNF care have been met. 
There are no medical records provided to verify if the SNF care is medically necessary. Therefore, we decided 
that the Plan does not have to pre-approve SNF care.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on October 12, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the laboratory services by a contract provider. The file does not show that the 
plan provided notice that the laboratory services would not be covered. Under Medicare rules, this means the 
laboratory services are considered approved by the plan. Therefore, we decided that the Plan has to pay for the 
laboratory services provided on October 12, 2021.  
 
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 a pneumatic compression device (E0676). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that this device is medically 
necessary. The Plan denied your request. The Plan says a PCD that provides intermittent limb compression for 
the purpose of prevention of venous thromboembolism is a preventive service and is excluded from coverage. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pre-approve a pneumatic compression device (E0676).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found you appear to be more stable and improving and should only require short-term 
additional acute care services that can be safely administered at the current facility until feeding status is more 
stable and when appropriate for a lower level of care. There are no services at the LTACH that you require that 
are not already available and covered at the current facility. Transfer to LTACH is not medically necessary as it 
would not be clinically advantageous at this time. Completion of treatment at the current location is 
recommended. 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the over-the-counter drugs purchased from March 18, 2021, 
through November 15, 2021. 
 
You asked the Plan to pay for the over-the-counter drugs. You say that you would like to be reimbursed for the 
over-the-counter drugs you purchased. The Plan denied your request. The Plan says this claim has not been 
billed appropriately. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items. However, the 
Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case 
 
In this case, the Evidence of Coverage specifies that reimbursement for OTC items is only provided when the 
over-the-counter health system online system, the call center, and enabled stores are all down at the same time. 
There is no evidence that these items were purchased during a time when the over-the-counter health system 
online system, the call center, and enabled stores were all down at the same time.  Therefore, we decided that 
the Plan does not have to pay for the over-the-counter drugs purchased from March 18, 2021, through 
November 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Denosumab injection services (J0897) to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve Denosumab injection services. You say that these services are medically 
necessary for your condition. The Plan denied your request. The Plan says there are in-network providers who 
are able to provide this service. 
 
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 
Denosumab injection services (J0897) to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified mass spectrometry provided along with drug 
testing on November 29, 2021. 
 
You asked the Plan to pay for the unspecified mass spectrometry. You say that this was medically necessary 
drug testing. The Plan denied your request. The Plan says the drug testing was approved for payment, but code 
83789 is noncovered specimen validity testing. 
 The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the unspecified mass spectrometry have not been met. Specifically, we find that the testing 
described by the billed code is considered specimen validity testing which is not separately payable. Therefore, 
we decided that the Plan does not have to pay for the unspecified mass spectrometry provided along with drug 
testing on November 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a walking boot provided on August 19, 2021. 
 
You asked the Plan to pay for walking boot. You say that the original boot you were given was too small so 
you needed this larger size. The Plan denied your request. The Plan says the denial of payment for this item is 
correct, because you have not submitted proper documentation showing that the boot has been paid for to 
support reimbursement. 
 
The Plan must follow Medicare rules. Medicare rules say that the beneficiary must submit to the Plan sufficient 
information to determine whether payment is due and the amount of payment.  
 
We looked at the file and Medicare rules. You are requesting reimbursement for a walking booth you received 
on August 19, 2021. However, you have not submitted information to the Plan showing the payment you have 
made for this item. Without this information, we cannot determine whether reimbursement is due directly to 
you or  if so  what the correct amount of payment should be. Please submit proof of payment to the Plan so 
the proper reimbursement amount can be determined. Based on this information, we decided that Medicare 
rules for coverage of walking boot have not been met. Therefore, we decided that the Plan does not have to pay 
for a walking boot provided on August 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a power scooter (K0823) provided November 23, 2021. 
 
You asked the Plan to pay for the power scooter. You say that the item was medically necessary. The Plan 
denied your request. The Plan says the claim was billed with an inappropriate modifier. 
 
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 K0823 is not supported in the medical record. Specifically, the KJ modifiers were 
incorrectly billed for a capped rental item. Based on this information, we decided that Medicare rules for 
coverage of the power scooter have not been met. Therefore, we decided that the Plan does not have to pay for 
a power scooter (K0823) provided November 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 2D oral/facial photographic image obtained intra-orally 
or extra-orally (D0350) provided January 21, 2022. 
 
You asked the Plan to pay for the 2D oral photographs. You say that you have coverage for x-rays and the 
dentist advised it would be covered. The Plan denied your request. The Plan says this service is not covered 
under your 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. 
 
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 2D 
oral/facial photographic image obtained intra-orally or extra-orally (D0350) provided January 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided by an out-of-network provider 
on July 26, 2021. 
 
You asked the Plan to pay for chiropractic services. You say that the claims representative said the service code 
billed did not require pre-authorization. You say that the claim should be reconsidered and reprocessed for 
appropriate payment. The Plan denied your request. The Plan says prior authorization was not obtained by the 
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 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 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 chiropractic services provided by an out-of-
network provider on July 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 3g/kg of Gamunex. 
 
You asked the Plan to pre-approve 3g/kg of Gamunex. You say that the clinical documentation provided 
supports the need for the amount of the drug being requested. The Plan denied your request. The Plan says the 
appellant's request exceeds the dosing frequency and duration of injections indicated by acceptable standards of 
medical practice.  
The Plan follows Medicare rules. Medicare rules say that medications administered for treatment of a disease, 
and which exceed the frequency or duration of injections indicated by accepted standards of medical practice 
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 3g/kg of Gamunex. Our reviewer says 
that the criteria for coverage of the requested supply have not been met. Our physician reviewer found the 
record indicates that the requested medication is being used for a medically accepted indication. Medicare rules 
do not limit the dose of a medication unless restricted by the compendia. The prescriber has requested a year 
supply. The record provided is insufficient to establish the medical necessity, as defined by Medicare rules, of a 
year supply. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 3g/kg of Gamunex have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 3g/kg of Gamunex.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided by an out-of-network provider 
from February 11, 2022, through February 23, 2022. 
 
You asked the Plan to pay for chiropractic services. You say that the office, individual provider and referring 
provider are participating providers and the enrollee is entitled to all Medicare approved services. You say that 
the services were medically necessary and should be approved for payment. The Plan denied your request. The 
Plan says the enrollees plan excludes coverage for this out-of-network service. 
  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 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 chiropractic services provided by an out-of-
network provider from February 11, 2022, through February 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120) and 
prophylaxis (D1110) provided January 5, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the periodic oral exam and dental cleaning provided OON. You say that you 
were told you would have OON dental benefits. The Plan denied your request. The Plan says these services are 
not covered when provided OON. 
 
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 periodic 
oral exam and dental cleaning provided OON when the services are provided in-network. 
 
We looked at the file and Medicare rules. In this case the services were provided OON. Your benefit plan does 
not include OON benefits. Based on this information, we decided that the Plan's rules for coverage of the 
periodic oral exam and dental cleaning provided OON have not been met. Therefore, we decided that the Plan 
does not have to pay for the periodic oral evaluation - established patient (D0120) and prophylaxis (D1110) 
provided January 5, 2022, by an out-of-network (OON) provider.  
 Your complaint about potentially being provided misinformation when you signed up for your plan 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.