Persius/hicric huggingface dataset:
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 a specialist office visit. You say that you think it is irresponsible for the Plan 
to send you to any other location other than the requested provider for your follow up care, as you are an 
existing patient with them. The Plan denied your request. The Plan says the member can safely be redirected to 
an in-network tertiary hepatologist. 
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve speech therapy visits in your home. 
 
You asked the Plan to pre-approve the home health services. You say that you had a stroke that has affected 
your speech. You say that you have made progress but are in desperate need of speech therapy. You also say 
that additional speech therapy will allow you to be more independent. The Plan denied your request. The Plan 
says while the speech therapy services are necessary, speech therapy services in your home are not. 
 
The Plan must follow Medicare rules. The rules say that an enrollee must be homebound for home health care 
services to be covered.  
 
The file does not show that you are homebound. Therefore, we decided that the Plan does not have to pre-
approve speech therapy visits in your home.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the genetic testing panel (0242U) provided on January 25, 2022. 
 
You asked the Plan to pay for genetic testing. You say that this is an FDA approved test which was medically 
necessary and ordered by the enrollee's provider. The Plan denied your request. The Plan says that the genetic 
testing was not ordered/approved by a treating provider on or before January 25, 2022. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the records provided include a Test Requisition and Statement of 
Medical Necessity which is signed and dated by the enrollee and the enrollees provider on January 19, 2022. 
The medical records included also show that the provider who ordered this test is/was treating this enrollee. 
The Plan has not provided any other reason for denial in this case; the Plans denial is not substantiated. 
Therefore, we decided that the Plan has to pay for the genetic testing panel (0242U) provided on January 25, 
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: Unfavorable

 
We decided that the Plan does not have to pre-approve medial branch blocks at L4-S1 for the enrollee. 
 
You asked the Plan to pre-approve the blocks. You say that the enrollee has failed physical therapy, non-
steroidal anti-inflammatory drugs (NSAIDs), and a home exercise regimen. The Plan denied your request. The 
Plan says the records do not document why the provider is changing the levels of the medial branch block for 
the second injection. 
 
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 blocks. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this request exceeds utilization requirements. Only two levels bilaterally in a section at a time within 
a six month period may be treated. Therefore, the request is considered 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 blocks have not been met. Therefore, we decided that the Plan does not have 
to pre-approve medial branch blocks at L4-S1 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an eye exam () to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the eye exam. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they are non-
emergent and the same level of care can be provided in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an eye exam () 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 pre-approve a partial upper denture (D5213). 
 
You asked the Plan to pre-approve the dental item. You say that the denture you had done previously is not 
comfortable. You say that you cannot eat well. You also say that you need a denture again. The Plan denied 
your request. The Plan says your benefit for the requested partial upper denture 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 partial upper denture was exhausted on date of service May 24, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a partial upper denture (D5213).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gradient compression stockings (A6549) and a gradient 
compression wrap (A6545). 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says these items are not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code and 
A6545 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. The rules say that compression stockings described by code A6549 are noncovered 
because they do not meet the statutory definition of a surgical dressing. 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare or 
the Plan. Although these items may be appropriate, they do not fall into a covered benefit category. 
Additionally, the compression stockings are noncovered because they do not meet the statutory definition of a 
surgical dressing. Therefore, we decided that the Plan does not have to pre-approve gradient compression 
stockings (A6549) and a gradient compression wrap (A6545).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hearing aid molds. 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says these items are not covered under your contractual policy. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case.   
  
Though the Plan offers a hearing aid benefit in excess of Medicare coverage, the requested items are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve hearing aid 
molds.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pulmonary care to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the pulmonary care. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they are 
non-emergent, and the same level of care can be provided in-network 
 
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 
pulmonary care 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 hearing aids (V5298), fitting of hearing aid (V5011), and ear 
impression (V5275) received on March 8, 2022. 
 
You asked the Plan to pay for hearing aids, fitting of hearing aid, and ear impression. You say that you want 
the Plan to cover these services. The Plan denied your request. The Plan says these services are not covered 
with an out-of-network provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when the Plan's network providers are utilized.  
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aids, fitting of hearing aid, and ear impression have not been met. Specifically, you used an 
out-of-network provider and therefore, these services are not covered. Therefore, we decided that the Plan does 
not have to pay for hearing aids (V5298), fitting of hearing aid (V5011), and ear impression (V5275) received 
on March 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an outpatient visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an outpatient visit. You say that you have seen in-network providers, but 
they have not been able to help. The Plan denied your request. The Plan says the services have been requested 
by an out-of-network provider and there are in-network providers available. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an outpatient visit to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36556 billed for date of service December 
26, 2021. 
 
You asked the Plan to pay for procedure code 36556. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 36556 is bundled into payment for code 33206. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 36556 
is a column II code to column I code 33206. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 36556 billed for date of service December 26, 
2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 75 routine transportation mileage (A0170). 
 
You asked the Plan to pre-approve additional mileage. You say that the enrollee is having a procedure done. 
You say that the enrollee should not drive for 72 hours afterwards. You also say that the enrollee will require 
transportation to and from the procedure. The Plan denied your request. The Plan says trips exceeding 50 miles 
driving distance 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 each one-way trip does not exceed 50 miles of driving 
distance.  
 
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. Specifically, the file indicates 
that additional mileage beyond the 50 miles driving distance is not covered. Therefore, we decided that the Plan 
does not have to pre-approve an additional 75 routine transportation mileage (A0170).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on October 27, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network, and it was determined 
these services can be received in-network. 
 
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 laboratory services provided on October 27, 2021, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on February 15, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says services from non-participating providers are not covered unless 
preauthorized. 
 
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 laboratory services provided on February 15, 
2022, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service April 3, 
2022. 
 You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76705 billed for date of service April 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a FreeStyle Libre CGM. You say that you cannot use your hands and you 
cannot even hold a pencil. The Plan denied your request. The Plan says you do not meet criteria for the 
requested device. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a FreeStyle 
Libre CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle 
Libre continuous glucose monitor (CGM).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 non-emergency transportation rides (T2003). 
 
You asked the Plan to pre-approve non-emergency transportation. You say that the requested transportation is 
necessary. The Plan denied your request. The Plan says you have not been diagnosed with congestive heart 
failure. The Plan also says that the criteria for approval have not been met. 
 
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 enrollees have been diagnosed with both diabetes and congestive heart failure to be eligible to receive the transportation benefit from a plan-specified vendor.  
 
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. Specifically, the file does not 
indicate that you have been diagnosed with both of the required conditions to make you eligible for coverage. 
Therefore, we decided that the Plan does not have to pre-approve 12 non-emergency transportation rides 
(T2003).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional routine transportation benefits for the 2022 year. 
 
You asked the Plan to provide additional transportation. You say that this transportation is medically necessary 
for the enrollee to continue and complete treatment. The Plan denied your request. The Plan says the Plan's 
supplemental transportation benefit covers a maximum of 50 one-way trips per year. Additional trips are not a 
covered benefit. 
 
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 50 trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that your request exceeds the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to provide additional routine transportation benefits for the 2022 year.