Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer.
You asked the Plan to pre-approve the Vertiflex Superion Spacer. You say that you would like reconsideration because this device is medically necessary. The Plan denied your request. The Plan says the member does not meet Medicare criteria for coverage.
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 Vertiflex Superion Spacer. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental and more research is needed to show its safety and efficacy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Vertiflex Superion Spacer have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a new continuous positive airway pressure (CPAP)
device.
You asked the Plan to pre-approve the device. You say that this should be paid for. The Plan denied your
request. The Plan says the previous unit that was being was recalled.
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 device. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found you use continuous positive airway pressure in the treatment of obstructive sleep apnea.
You obtained a Phillips CPAP in 2020, and your unit was subject to recall by the manufacturer. You are
requesting replacement, which is the responsibility of the manufacturer, and therefore is not covered by the
plan.
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 device have not been met. Therefore, we decided that the Plan does not have
to pre-approve a new continuous positive airway pressure (CPAP) device.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve bioimpedance spectroscopy (BIS).
You asked the Plan to pre-approve the BIS. You say that you would like reconsideration because the requested service is medically necessary. The Plan denied your request. The Plan says that this service is experimental.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the BIS. Our reviewer says that bioimpedance spectroscopy for breast cancer related lymphedema assessment has become a standard of care for prevention and treatment. Our physician reviewer found clinical measurements are obtained initially to establish a baseline before breast cancer treatments and afterward at intervals to track changes during treatment. Alternatively, changes in arm circumference or volume relative to the contralateral normal limb can be performed. Given that the highest risk of developing lymphedema is within the first three years of treatment and that early intervention can limit progression of disease, the service is reasonable and medically 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 BIS have been met. Therefore, we decided that the Plan has to pre-approve bioimpedance spectroscopy (BIS).
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the removal of lateral exostosis (D7471).
You asked the Plan to pre-approve the removal of lateral exostosis (D7471). You say that the member is having
trouble eating solid foods and does not have the ability to talk. You say that he needs dental surgery to fix his
ability to talk and eat normal. The Plan denied your request. The Plan says the service is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's 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 pre-approve the
removal of lateral exostosis (D7471).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy service (90834) rendered by the OON
provider on July 16, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network
provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan
does not have to pay for the psychotherapy service (90834) rendered by the OON provider on July 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for portable oxygen equipment provided on
October 5, 2021.
You asked the Plan to waive the copayment for the portable oxygen equipment. You say that the services
should be covered as you have returned the equipment. The Plan denied your request. The Plan says the
coinsurance applied correctly based on the item provided and that you had the equipment from 10/01/2021, to
10/05/2021.
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 20%
coinsurance for Durable medical equipment (DME) and related supplies.
You have been asked to pay a 20% coinsurance for portable oxygen equipment ($163.26 x 20% = $32.65).
Portable oxygen equipment falls within the Durable medical equipment (DME) and related 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 portable oxygen equipment provided on
October 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the visit (99203) provided on August 2, 2021.
You asked the Plan to pay for the visit. The Plan denied your request. The Plan says the services were billed
incorrectly.
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, the CPT Code Manual definition of code 99203 is "Office or other outpatient visit for the
evaluation and management of a new patient, which requires a medically appropriate history and/or
examination and low level of medical decision making. When using time for code selection, 30-44 minutes of
total time is spent on the date of the encounter."
We find that CPT code 99203 is not supported in the medical record. Specifically, the records provided show
that the services in question were billed with an emergency room place of services (POS 23). It is inappropriate
to bill code 99203 for an emergency department visit.
Based on this information, we decided that Medicare rules for coverage of the visit have not been met.
Therefore, we decided that the Plan does not have to pay for the visit (99203) provided on August 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit for the evaluation and management of an
established patient (99348) rendered by the OON provider on September 29, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network
provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan
does not have to pay for the home visit for the evaluation and management of an established patient (99348)
rendered by the OON provider on September 29, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (82542, 80307, G0483, 84228) provided on
September 29, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for drug testing. You say that this is supported in the records. The Plan denied your
request. The Plan says this was not authorized.
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 drug testing (82542, 80307, G0483, 84228)
provided on September 29, 2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee on May 8, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.
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 services at issue in this appeal. The Plan did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for the services provided to the enrollee on May 8, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network
provider on September 2, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.
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 services at issue in this appeal. The Plan did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network
provider on September 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on September 27, 2021.
You asked the Plan to waive the copayment for an office visit. You say that you should not be charged a copayment for preventative care. The office visit was for a physical. The Plan denied your request. The Plan says they viewed the records, and the office visit was not a routine physical. The proper copayment was applied.
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 $20 copayment for a Primary Care Physician's office visit.
You have been asked to pay a $20 copayment for an office visit. An office visit falls within the Physician/Practitioner services, including doctor's office visits 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 an office visit provided on September 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on August 16, 2021.
You asked the Plan to pay for the dental service. You say that you were diagnosed with gingivitis. You say that this required you see the dentist every 3 months. You say that you are back down to every 6 months. You also say that this should be covered. The Plan denied your request. The Plan says periodontal maintenance is not listed as a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the periodontal maintenance is not among those covered under this benefit. Additionally, the file shows that you were advised this service was not covered when you called the Plan prior to the date of service. Therefore, we decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on August 16, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health care visits to be provided by an out-ofnetwork
(OON) provider.
You asked the Plan to pre-approve home health. You say that you accepted this enrollee in good faith and the
denial should be overridden as the care provided is medically necessary. The Plan denied your request. The
Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the
Plan and the enrollee can receive care from an in-network home health agency.
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
home health care visits to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lift chair purchased on September 3, 2021.
You asked the Plan to pay for the lift chair. You say that the item is medically necessary. The Plan denied your
request. The Plan says they cannot reimburse durable medical equipment unless purchased from a DME
supplier enrolled in Medicare.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is
not enrolled in the Medicare program.
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare
program. Therefore, we decided that the Plan does not have to pay for the lift chair purchased on September 3,
2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (81003, 87086) rendered by the out-of-network (OON) provider on October 23, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue.
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the laboratory services (81003, 87086) rendered by the out-of-network (OON) provider on October 23, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on September 24, 2021.
You asked the Plan to waive the copayment for the laboratory services. You say that you do not remember ever paying for these services before. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
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 $25 copayment for lab services. You have been asked to pay a $25 copayment for the laboratory services. The laboratory services fall within the Outpatient Hospital Services 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 laboratory services provided on September 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), bitewing x-rays (D0274), resin-based composite of one surface (D2330), resin-based composite of three surfaces (D2332), and surgical extraction (D7210) provided on October 12, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the comprehensive oral evaluation, bitewing x-rays, resin-based composites, and surgical extraction. You say that the Plan referred you to this treating provider. You also say that the dental referral was not correct, and you owe $638 that you cannot pay. The Plan denied your request. The Plan says services performed by an OON provider are not covered because your healthcare plan does not have OON benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for 100% of the cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), bitewing x-rays (D0274), resin-based composite of one surface (D2330), resin-based composite of three surfaces (D2332), and surgical extraction (D7210) provided on October 12, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on May 28, 2021.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered screening service.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on May 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical pathology provided on August 27, 2021, by an
OON provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were rendered by an out-of-network provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the surgical pathology provided on August 27,
2021, by an OON provider.