Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation (D9310) provided on March 22, 2022. 
 
You asked the Plan to pay for a consultation. You say that this should not be your responsibility since you took 
the necessary steps to ensure the visit would be covered. The Plan denied your request. The Plan says a 
consultation (D9310) is not covered by your routine dental 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 a 
consultation (D9310) provided on March 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) system and 
supplies (K0553, K0554). 
 
You asked the Plan to pre-approve a CGM system and supplies. You say that the requested monitor and 
supplies are needed. The Plan denied your request. The Plan says your request is not medically necessary. 
 
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, require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results or have had an in-person visit with their treating physician to assesses adherence to their 
CGM regimen and diabetes treatment plan. Based on this information, we decided that Medicare rules for 
coverage of a CGM system and supplies have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM) system and supplies (K0553, K0554).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcatheter aortic valve replacement (TAVR/TAVI) 
with prosthetic valve; percutaneous femoral artery approach (33361). 
 
You asked the Plan to pre-approve a TAVR procedure. You say that the requested procedure is medically 
necessary due to the enrollee's nonrheumatic aortic. The Plan denied your request. The Plan says the requested 
procedure and associated inpatient admission requested does not meet the requirements for approval. 
 
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 a TAVR procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the echocardiogram showed moderate aortic stenosis and mild aortic regurgitation. 
Guidelines would not support aortic valve replacement based on the submitted medical records. As a result, at 
this time the requested TAVR would not be considered medically necessary in this enrollee's clinical 
management based on the submitted documentation. 
 
 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 TAVR procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; 
percutaneous femoral artery approach (33361).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services (90834) provided on May 12, 2021 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the psychotherapy services. 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 were 
non-emergent and prior authorization was not obtained. 
 
  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 psychotherapy services (90834) provided on May 
12, 2021 by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services you received in Germany on July 5, 
2021. 
 
You asked the Plan to pay for the ambulance services. You say that you had an accident while in Germany and 
you were unable to obtain codes for some of the services.  You said that you have paid for these services out-
of-pocket and wish to be reimbursed. The Plan denied your request. The Plan says ambulance transport outside 
of the country is not covered.  
 
The Plan must follow Medicare rules. Medicare rules say that Medicare does not cover services outside of the 
United States. Your plan offers an additional worldwide emergency and urgently needed care benefit.  
However, ambulance services outside of the country are excluded from coverage. Therefore, we decided that 
the Plan does not have to pay for ambulance services you received in Germany on July 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the colorectal cancer screening (G0105) provided on 
February 16, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the colorectal cancer screening.. You say that these services were medically 
necessary. The Plan denied your request. The Plan says the services were provided out-of-network and were 
not approved in advance. 
  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 colorectal cancer screening (G0105) provided 
on February 16, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the respiratory assist device (E0470) provided on August 9, 2021. 
 
You asked the Plan to pay for the respiratory assist device (E0470). 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. 
 
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. The Plan has not provided sufficient evidence to show that Medicare criteria has 
not been met. The Plan has not disclosed if the enrollee was given a purchase option in the 10th month or if the 
purchase option was exercised or not. Furthermore, September 4, 2018, through September 4, 2019 is a total of 
12 complete months, not 13 as the Plan has indicated. Therefore, we decided that the Plan has to pay for the 
respiratory assist device (E0470) provided on August 9, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an MRI provided on September 15, 2020. 
 
You asked the Plan to waive the copayment for an MRI. You say that your deductible was met, and you do not 
understand why your share is $75. The Plan denied your request. The Plan says the copayment applied is 
correct. 
 
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 $75 
copayment for advanced imaging services at an independent diagnostic testing facility (IDTF).  
 
You have been asked to pay a $75 copayment for an MRI. An MRI falls within the Outpatient Diagnostic Tests 
and Therapeutic Services and Supplies 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 copayment 
for a MRI provided on September 15, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on September 30, 
2021. 
 
You asked the Plan to pay for rest home visit. You say that the provider has no prior knowledge of which 
patients he will be required to see. The Plan denied your request. The Plan says the non-contract provider failed 
to obtain the required 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 a domiciliary or rest home visit provided on 
September 30, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory (lab) services provided on February 24, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says original Medicare 
is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for laboratory (lab) services provided on February 24, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of an implantable loop recorder (ILR).  
You asked the Plan to pre-approve insertion of an ILR. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that certain cardiac event monitors are covered when 
specific criteria are met. 
 
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 insertion of an ILR. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found there is no documentation provided 
to suggest a history of unexplained syncope, cryptogenic stroke or any other apparent indication for an ILR. In 
summary, there is insufficient documentation to support the medical necessity for insertion of an ILR in this 
enrollees 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 insertion of an ILR have not been met. Therefore, we decided that the Plan does 
not have to pre-approve insertion of an implantable loop recorder (ILR).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit with a chiropractor (99203, 98941) to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit with a chiropractor. You say that the chiropractic offices 
listed as preferred are out of town and significantly inconvenient for the enrollee. You also say your office 
would pose less hardship for her. The Plan denied your request. The Plan says services must be provided by 
network providers. There are in-network providers that can provide this service for the enrollee. 
 
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 office visit with a chiropractor (99203, 98941) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency room visit provided on January 12, 2022 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the emergency room visit. 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 the 
provider does not participate with Medicare. 
 
  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 emergency room visit provided on January 12, 
2022 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ConfirmMDx epigenetic assay provided to the enrollee 
on April 29, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this was not reported correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that some laboratory require the use of a unique 
identifier. 
 
The appropriate DEX Z-code was submitted on the claim in this case. Based on this information, we decided 
that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does 
not have to pay for the ConfirmMDx epigenetic assay provided to the enrollee on April 29, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on March 16, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the services were provided out-of-network and were not approved 
in advance. 
 
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 home health services provided on March 16, 
2022, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99601 and 99602 billed for date of service 
January 13, 2022. 
 
You asked the Plan to pay for procedure codes 99601 and 99602. You say that these codes are covered and no 
authorization is needed. The Plan denied your request. The Plan says the billed codes are invalid for Medicare 
purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure codes 99601 and 99602 have a Status Indicator of I on the Physician Fee Schedule. This means that procedure codes 99601 and 99602 are not valid for Medicare purposes. Based on this 
information, we decided that Medicare rules for coverage of procedure codes 99601 and 99602 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 99601 and 99602 billed for 
date of service January 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the ventilator is to be used for the treatment 
of COPD. The Plan denied your request. The Plan says the request for a home mechanical ventilator set in 
iVAPS mode with Auto-EPAP (AE) that could be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 
 
 
 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has severe combined 
obstructive and restrictive lung disease and HFrEF. He was recently admitted with exacerbation of HFrEF, and 
ABG was consistent with mild acute hypoventilation. There is no documentation of chronic CO2 retention on 
an ABG done as an outpatient while stable. If the enrollee does have chronic CO2 retention, he may benefit 
from BiPAP with AVAPS during sleep.  Medicare does not cover a home ventilator when used as BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and an additional 
periapical x-ray (D0230) provided on January 31, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says that your benefit for periapical x-rays has already been exhausted. 
The Plan also says that a limited oral evaluation (D0140) is not covered by your supplemental dental 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, certain limitations apply. The record 
shows your benefit for periapical x-rays was exhausted on date of service January 31, 2022. A limited oral 
evaluation is not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for a limited oral evaluation (D0140) and an additional periapical x-ray (D0230) provided on January 31, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit and a cystourethroscopy (52000, 99215) 
to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the office visit and a cystourethroscopy. 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 were non-emergent and prior authorization was not obtained. 
 
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 office visit and a cystourethroscopy (52000, 99215) to be provided by an out-of-network (OON) provider.