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 September 30, 2022. 
 
You asked the Plan to pay for an office visit. You say that you are appealing this denial. The Plan denied your 
request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on September 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a maxillary complete denture (D5110) provided on 
November 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your $1,000 annual dental benefit maximum 
allowance for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service October 26, 2022. 
Therefore, we decided that the Plan does not have to pay for a maxillary complete denture (D5110) provided on 
November 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crowns (D6750), and pontics (D6240). 
 
You asked the Plan to pre-approve retainer crowns, and pontics. You say that you would like the Plan to 
approve these services. The Plan denied your request. The Plan says these services have been correctly denied. 
 
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 retainer 
crowns, and pontics 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 pre-approve retainer crowns, and pontics. Our 
physician reviewer found the documentation does not meet the criteria for coverage for fixed bridges replacing 
missing teeth #'s 4, 12, 13, 14, 15,18 and 31. 
  
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 retainer crowns, and pontics have not been met. Therefore, we decided that the 
Plan does not have to pre-approve retainer crowns (D6750), and pontics (D6240).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor billed for date of service July 
30, 2022. 
 You asked the Plan to pay for the billed services. You say that you provide quality healthcare products to the 
enrollee. The Plan denied your request. The Plan says the documentation does not support the billed supply 
code. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order, proof of delivery, or relevant medical records which 
support medical necessity for the supplies provided in this case. Based on this information, we decided that the 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for 
the continuous glucose monitor billed for date of service July 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant Reveal testing (81479) provided on May 2, 
2022. 
 
You asked the Plan to pay for the Guardant Reveal testing. You say that this test was medically necessary and 
appropriate for this enrollee. The Plan denied your request. The Plan says this test is not recommended by the 
National Comprehensive Cancer Network and is denied as a non-covered test. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. Once this is complete, the test is assigned a 
reimbursement rate and a unique test identifier. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as non-covered. This 
determination was made and is specific to the test at issue. Based on this information, we decided that Medicare rules for coverage of the Guardant Reveal testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the Guardant Reveal testing (81479) provided on May 2, 2022.
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. 
 
You asked the Plan to pre-approve IRF care. You say that you would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says the inpatient rehabilitation facility (IRF) 
services you are requesting do not meet the requirements for approval. 
 
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. Our 
physician reviewer found the enrollee does not have complex or intensive rehabilitation needs and does not 
require frequent physiatry oversight or rehabilitation nursing.  
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.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the outpatient left total hip arthroplasty (27130). 
 
You asked the Plan to pre-approve the outpatient surgery. You say that at this point the enrollee has exhausted 
conservative treatments and the next step would be total hip arthroplasty. The Plan denied your request. The 
Plan says the requested outpatient left total hip arthroplasty is not medically 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 outpatient surgery. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found detailed documentation is not evident regarding a trial and failure of recent, 
reasonable, comprehensive less invasive conservative care measures. The last formal therapy session was over 
a year ago. There was indication that the cortisone injections have just quit providing benefit (with the last 
injection date not documented.) Moreover, the x-rays were noted to show moderate degenerative changes 
involving his left hip, still reasonable preservation of joint space. There are limited large-scale, long-term 
references showing the safety and efficacy of the requested surgery in this clinical setting. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested left total hip arthroplasty, in this case, is not medically 
reasonable or 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 outpatient surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the outpatient left total hip arthroplasty (27130).
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 13121 billed for date of service May 31, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says that a modifier 
should be considered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code.  
 
We find that CPT code 13121 is a minor procedure. The claim shows that the services were provided in the 
emergency department. The physician who performs the emergency room service bills for the surgical 
procedure without a modifier. Based on this information, we decided that Medicare rules for coverage of the 
billed services have been met. Therefore, we decided that the Plan has to pay for procedure code 13121 billed 
for date of service May 31, 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: Drugs
Decision: Partially Favorable

 
We decided that the Plan has to waive the cost share for two injections provided on January 3, 2022, and on 
January 6, 2022. We decided that the Plan does not have to waive the cost share for Medicare Part B 
prescription drugs.  
 You asked the Plan to waive the cost share for Medicare Part B prescription drugs provided on January 3, 2022, 
to January 6, 2022.. You say that you disagree with the cost share The Plan says that this cost sharing was 
charged correctly. 
 
We decided that the Plan has to waive the cost share for two injections provided on January 3, 2022, and 
on January 6, 2022.  
 
The following codes J1626 and J1642 are packaged codes and are not separately payable. They are also 
excluded from the physician fee schedule. 
 
Therefore, we decided that the Plan has to waive the cost share for two injections provided on January 3, 2022, 
and on January 6, 2022.  
 
We also decided that the Plan does not have to waive the cost share for Medicare Part B prescription 
drugs. 
 
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% 
coinsurance for Medicare Part B prescription drugs. The total amount you are being asked to pay is $263.34 
towards your out of pocket maximum. Therefore, we decided that the Plan does not have to waive the cost 
share for Medicare Part B prescription drugs. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMs Heart Failure (HF) system. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found that the CardioMEMs was approved by 
the Food and Drug Adminiistration (FDA) in 2014. Nonetheless, there remains a dearth of randomized, blinded 
clinical studies examining long-term clinical outcomes establishing the value of CardioMEMS in patient 
management. As a result, at this time the CardioMEMS system would not be considered medically appropriate 
and necessary in this enrollee's clinical management. 
 
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 a CardioMEMs Heart Failure (HF) system.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services you received on October 
31, 2022. 
 
You asked the Plan to pay for the outpatient mental health services. You say that this provider had been a 
previous member of your team and is a relapse prevention provider. Your psychiatrist instructing you to resume 
counseling. The Plan denied your request. The Plan says you saw a provider type that is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that the only provider types eligible to provide 
Medicare-covered mental health services are as follows: Physicians, Clinical Psychologists, Clinical Social 
Workers, Clinical Nurse Specialists, Nurse Practitioners, Physician Assistants, Certified Nurse-Midwives, 
Independently Practicing Psychologists, and Certified Registered Nurse Anesthetists. The provider that you 
saw is a Licensed Professional Counselor, which is not a covered provider type for Medicare. Therefore, we 
decided that the Plan does not have to pay for outpatient mental health services you received on October 31, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment (DME) 
provided on November 08, 2022. 
 
You asked the Plan to waive the coinsurance for durable medical equipment (DME). You say that you disagree 
with the coinsurance. 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 20% 
coinsurance for durable medical equipment (DME). 
 
You have been asked to pay 20% coinsurance for durable medical equipment (DME). This item/service falls 
within the durable medical equipment (DME) benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance 
for durable medical equipment (DME) provided on November 08, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation and cleaning (D1110, D0120) 
provided on September 16, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 11, 2022, 
February 21, 2022. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation and 
cleaning (D1110, D0120) provided on September 16, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on June 22,  2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. The Plan denied your 
request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on June 22, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on June 22,  2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor billed for services on August 
30, 2022. 
 
You asked the Plan to pay for the billed services. You say that clinical indications are not enforced. The Plan 
denied your request. The Plan says the documentation does not support the billed supply code. The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order, proof of delivery, or relevant medical records which 
support medical necessity for the supplies provided in this case. Based on this information, we decided that the 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for 
the continuous glucose monitor billed for services on August 30, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on November 5,  2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the service 
should be covered due to this being an ambulance service The Plan denied your request. The Plan says these 
services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on November 5, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on November 5,  2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on June 15, 2021, to July 20, 2021. 
 
You asked the Plan to pay for dental services. You say that you would like this paid. The Plan denied your 
request. The Plan says this claim has been untimely filed. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for dental services was not filed until October 26, 2022. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for dental services provided on June 15, 2021, to July 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant Reveal testing (81479) provided on January 18, 
2022. 
 
You asked the Plan to pay for the Guardant Reveal testing. You say that this test was medically necessary and 
appropriate for this enrollee. The Plan denied your request. The Plan says this test is not recommended by the 
National Comprehensive Cancer Network and is denied as a non-covered test. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. Once this is complete, the test is assigned a 
reimbursement rate and a unique test identifier. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as non-covered. This 
determination was made and is specific to the test at issue. Based on this information, we decided that Medicare rules for coverage of the Guardant Reveal testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the Guardant Reveal testing (81479) provided on January 18, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services (83521) provided on September 29, 2022. 
 
You asked the Plan to pay for laboratory services. You say that you expected these services to be paid because 
they had been covered for all of 2021. You say there may be a coding issue, but these are the same services you 
had been receiving previously. The Plan denied your request. The Plan says that these services are considered 
experimental/investigational and are considered not medically necessary. 
 
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. 
 
You were referred for laboratory services by a contract provider. The file does not show that the Plan provided 
notice that laboratory services would not be covered. Under Medicare rules, this means laboratory services is 
considered approved by the Plan. Therefore, we decided that the Plan has to pay for laboratory services (83521) 
provided on September 29, 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.