Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuation of care with an out of network (OON) 
provider. 
 You asked the Plan to pre-approve a continuation of care with an OON provider. You say that the enrollee has 
a past history with this provider. The Plan denied your request. The Plan says the requested provider is not 
uniquely qualified to treat the enrollee's condition. The Plan says that the services can be received from 
providers in the Plan's network. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 continuation of care with an OON 
provider. Our reviewer says that the criteria for coverage of OON care have not been met. Our physician 
reviewer found the enrollee is not currently receiving any active treatment and/or medical management of his 
condition that makes it medically necessary for him to continue care with the OON provider as requested. 
There is not anything unique about the enrollees condition that would make it medically necessary for him to 
continue care with the OON provider. The Plan has shown that they have in-network specialists who have the 
qualifications and expertise necessary to meet the current medical Standards of Care required for treatment of 
the enrollees condition.  The enrollees medical management and/or follow-up care can be safely transitioned 
to an in-network specialist at this time. 
 
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 continuation of care with an OON provider have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continuation of care with an out of network (OON) 
provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on May 29, 2020, billed with codes 
80050, 81015, and 82947. 
 
You asked the Plan to pay for the lab testing as billed. You say that the services should be paid. The Plan 
denied your request. The Plan says these codes are not payable.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
The code 80050 is not payable by Medicare. In this case, we have confirmed that code 82947 is a column II 
code to column I code 80053. This claim has not been billed with an appropriate modifier to bypass the edit. 
Code 81015 is also a Column II code in relation to code 81000, and there is a modifier indicator of 0, meaning 
no separate payment can be made even with a modifier. Based on the claim submitted, Medicare billing criteria 
have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing provided on 
May 29, 2020, billed with codes 80050, 81015, and 82947.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device insertion. 
 
You asked the Plan to pre-approve the Vertiflex device insertion. You say that the enrollee has suffered from 
this condition for too long and has failed conservative approaches to treatment. You say that the procedure is 
medically necessary, and the authorization should be approved. The Plan denied your request. The Plan says 
the Vertiflex device is considered experimental/investigational. 
 
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 device insertion. 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 considered experimental. 
 
 
  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 device insertion have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Vertiflex device insertion.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99239) provided on April 8, 2022. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed services. 
 
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 99239 is hospital discharge day management of more 
than 30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, records do not show 30 
minutes were spent on this service. Based on this information, we decided that Medicare rules for coverage of 
the physician services have not been met.  
 
 
 
  
Therefore, we decided that the Plan does not have to pay for physician services (99239) provided on April 8, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for office visit on November 23, 2021, to 
January 05, 2022. 
 
You asked the Plan to waive the copayments for office visit. You say that you want to appeal the amount being 
charged. 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 a $45 
copayment for provider and professional services at specialists office. Covered services include consultation, 
diagnosis, and treatment by a specialist. Per negotiated rate with the provider's network applied a $40 
copayment for each date of service. $40 x 3 = $120. Therefore, results in the total cost sharing amount of $120. 
 You have been asked to pay a $40 copayment for each office visit. This item/service 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 copayments for office visit on November 23, 2021, to January 05, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on June 10, 2022, by an out-of-network (OON) provider.

You asked the Plan to pay for laboratory services. You say that you are appealing the claim payment denial. The Plan denied your request. The Plan says the services were provided out-of-network and were not approved in advanced.

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 June 10, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the xT genetic testing provided on April 7, 2022. 
 
You asked the Plan to pay for the xT genetic testing. You say that this is medically necessary testing. The Plan 
denied your request. The Plan says that lab testing must always report the DOS as the date the sample is 
collected. Therefore, this claim is billed with an incorrect DOS and cannot be paid. 
 
The Plan must follow Medicare rules. Medicare rules say that the correct DOS for lab claims may be the date 
the test is performed for tests that meet the criteria in the Medicare rules section. 
 
We looked at the file and Medicare rules. This is a molecular pathology test performed on a tumor tissue 
sample. This sample was obtained in the hospital setting as is appropriate. The Plan did not provide evidence to 
support whether the hospital stay was inpatient or outpatient as the exceptions to the date of service rule were 
not apparently considered. Based on this information, we decided that Medicare rules for coverage of the xT 
genetic testing have been met. Therefore, we decided that the Plan has to pay for the xT genetic testing 
provided on April 7, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endosteal implants on tooth #4, 7, 10 (D6010) and 
second stage implant surgery on tooth #4, 7, 10 (D6011). 
 
You asked the Plan to pre-approve implants and implant surgery. You say that you only need implants on three 
teeth. The Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
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 implants and 
implant surgery 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 implants and implant surgery. Our 
reviewer says that the coverage criteria has not been met. Our physician reviewer found that it is unclear as to 
how implants placed at the tooth #4,7 and 10 sites would allow for restoration of the remaining arch. Given the 
lack of clarity of the final treatment plan there can be no finding of medical necessity. 
 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 implants and implant surgery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve endosteal implants on tooth #4, 7, 10 (D6010) and second stage implant 
surgery on tooth #4, 7, 10 (D6011).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transportation services provided on April 24, 2022. 
 
You asked the Plan to pay for the services provided. You say that the denial is incorrect. The Plan denied your 
request. The Plan says the claim would be covered under Original Medicare. 
 
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 the transportation services provided on April 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740) and prefabricated post and core in 
addition to crown (D2954) provided on March 2, 2022. 
 
You asked the Plan to pay for the crown and prefabricated post and core in addition to crown. You say that you 
were advised these services would be covered. You also say that you did not know your policy had changed. 
The Plan denied your request. The Plan says these services are not covered expenses under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the crown 
(D2740) and prefabricated post and core in addition to crown (D2954) provided on March 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prosthetic protective cover. 
 
You asked the Plan to pre-approve the requested item. You say that  The Plan denied your request. The Plan 
says the item exceeds the enrollee's needs. 
 
The Plan must follow Medicare rules. Medicare rules say that lower limb prostheses are only covered under 
certain medical indications.  
 
 
 We looked at the file and Medicare rules. The records do not show that the enrollee has a need for protection 
against unusually harsh environmental situations. Based on this information, we decided that Medicare rules 
for coverage of the requested item have not been met. Therefore, we decided that the Plan does not have to pre-
approve a prosthetic protective cover.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit, x-ray, and the removal of a nail bed (73620, 
99203, 11750) provided on February 11, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit, x-ray, and removal of a nail bed. 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 an office visit, x-ray, and the removal of a nail bed 
(73620, 99203, 11750) provided on February 11, 2022 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3020). 
 
You asked the Plan to pre-approve the foot orthotics. 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 a covered benefit under your 
contractual policy or by Medicare for your condition. 
 
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. Additionally, Medicare rules say that with the exception of the situations described, orthopedic 
footwear wear billed using code L3020 will be denied as non-covered. Therefore, we decided that the Plan does 
not have to pre-approve foot orthotics (L3020).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a queen-sized adjustable bed. 
 
You asked the Plan to pre-approve a queen-sized adjustable bed. The Plan denied your request. The Plan says 
this type of bed is not medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The adjustable bed at issue in this appeal does not serve a purpose that is primarily medical in nature. This item 
is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a queen-sized adjustable bed.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a posterior interspinous decompression spacer 
procedure. 
 
You asked the Plan to pre-approve a posterior interspinous decompression spacer procedure.. You say that this 
procedure is considered safe and effective, as supported by its clinical benefits to patients, continued medical 
professional adoption, and strong clinical evidence with numerous peer-reviewed studies. The Plan denied your 
request. The Plan says a review of the current medical literature indicates that this service is considered 
experimental and investigational as it is not identified as widely used and generally accepted for the proposed 
use as reported in nationally recognized peer-reviewed medical literature published in the English language. 
 
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 posterior interspinous decompression 
spacer procedure. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found current evidence based medical guideline and peer 
reviewed literature do not fully support the spinal decompression device procedure over the gold standard of 
lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollees medical condition as discussed above. FDA indications include 
implantation of the Superion device at one or two adjacent lumbar levels in patients with moderate spinal 
stenosis in whom operative treatment is indicated at no more than two levels, from L1 to L5. This enrollee has 
multiple degrees of spinal stenosis, many not at FDA indicated levels of moderate spinal stenosis (including 
the planned level of implantation at L4-5). There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
Vertiflex Superion interspinous device at L4-5, 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 a posterior interspinous decompression spacer procedure have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a posterior interspinous decompression 
spacer procedure.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab services (81455) provided on September 15, 2021. 
 
You asked the Plan to pay for the lab services. You say that fafadsf The Plan denied your request. The Plan 
says that the claim did not contain a Dex-Z Code unique identifier required by Medicare. 
 
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 argues that the claim was not billed with the appropriate Dex-Z Code 
as required by the Medicare LCD. However, the Plan has not provided the LCD, nor the specific rule used to 
make its decision. Without supporting documentation, the Plan's denial cannot be substantiated. Therefore, we 
decided that the Plan has to pay for the lab services (81455) provided on September 15, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pair of progressive lenses glasses. 
 
You asked the Plan to pre-approve a pair of progressive lenses glasses. You say that you got single line lenses 
instead of progressive lenses and you cannot read or see anything up close. You also say you want the provider 
to remake the lenses and get progressive lenses instead. The Plan denied your request. The Plan says there is a 
$150 vision allowance for routine contact lenses or eye wear every two years. The Plan also says that you are 
not eligible for eyeglasses until August 10, 2024. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers up to $150 toward the cost of routine contact lenses or eye wear every two years. 
 
We looked at the file and the Plan's rules. You purchased a pair of glasses on August 9, 2022. Therefore, the 
benefit is exhausted for two years. The Plan says that you will not be eligible for another pair of glasses until 
August 10, 2024. Based on this information, we decided that the Plan's rules for coverage of a pair of 
progressive lenses glasses have not been met. Therefore, we decided that the Plan does not have to pre-approve 
a pair of progressive lenses glasses.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mastectomy sleeve bra (L8010, S9999) provided on April 
1, 2022. 
 
You asked the Plan to pay for a mastectomy sleeve bra. You say that this was medically necessary. The Plan 
denied your request. The Plan says this item is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a mastectomy sleeve (L8010) is denied as 
noncovered, since it does not meet the definition of a prosthesis.   
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a mastectomy sleeve bra have not been met. This item does not meet the definition of a prosthesis 
and is not covered. Therefore, we decided that the Plan does not have to pay for a mastectomy sleeve bra 
(L8010, S9999) provided on April 1, 2022.