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

 
We decided that the Plan does not have to pay for the self-administered drugs (A9270) provided from 
September 19, 2022, through September 20, 2022. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says these items are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs provided are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
(A9270) provided from September 19, 2022, through September 20, 2022.  
 Benefits for these items may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 7, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services provided. 
The Plan denied your request. The Plan says there is no authorization on file for the services rendered. 
 
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 provided on February 7, 2022, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve white glass with high gold content cap for bridge (D6750) Tooth 
#6 and 8. 
 
You asked the Plan to pre-approve dental services. You say that you were told by the provider this procedure is 
medically necessary. The Plan denied your request. The Plan says that the provider did not send the requested 
x-rays by the deadline date. 
 
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 dental 
services 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 dental services. Our physician reviewer 
found it is medically reasonable and necessary to replacing missing tooth #7 with a fixed bridge. The abutment 
retainers (#6 and 8) appear to have good bone support to provide support and stability for a fixed bridge. 
 
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 dental services have been met. Therefore, we decided that the Plan has to pre-
approve white glass with high gold content cap for bridge (D6750) Tooth #6 and 8.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on August 26, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for nursing facility care. You say that the records attached support the services being 
provided. The Plan denied your request. The Plan says prior authorization must be obtained prior to out of 
network services being rendered. 
 
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 nursing facility care provided on August 26, 2022, 
by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5050 x 2) purchased on 
May 19, 2021. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says these items are not payable as 
they were purchased from 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 purchased from a network hearing aid provider.  
 
We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plan contract states that enrollees may obtain 
hearing aids from any network hearing aid provider. However, the hearing aids in this case were purchased 
from an out-of-network provider. Therefore, we decided that the Plan does not have to issue reimbursement for 
the hearing aids (V5050 x 2) purchased on May 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on October 8, 
2022. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that you had to go to urgent care 
because your primary care provider would not call you back. 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 $60 
copayment for urgently needed services.  
 
You have been asked to pay the allowed amount of $50.58 which is less than the $60 copayment for an urgent 
care visit. This item/service falls within the urgently needed 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 an urgent care visit provided on October 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a podiatrist office visit provided on August 31, 2022. 
 
You asked the Plan to pay for a podiatrist office visit. You say that you are requesting a review because the 
claim was denied incorrectly and a previous visit was paid by the Plan for the same member. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a podiatrist office visit 
provided on August 31, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychotherapy visit provided on November 1, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for a psychotherapy visit. You say that the records attached support the services 
provided. The Plan denied your request. The Plan says there is no authorization on file for the services 
rendered. 
 
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 psychotherapy visit provided on November 1, 
2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided on September 6, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for anesthesia services. You say that the services were performed by an in-network 
provider. The Plan denied your request. The Plan says there is no prior authorization, and the services were 
rendered by an out-of-network provider. 
 
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 anesthesia services provided on September 6, 
2022, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound of the abdominal aorta (76706) provided on 
September 8, 2022. 
 
  You asked the Plan to pay for the ultrasound of the abdominal aorta. You say that you would like this denial to 
be reconsidered and reprocessed for payment. The Plan denied your request. The Plan says this was billed with 
diagnosis code Z13.6, defined as Encounter for screening for cardiovascular disorders, which is not considered 
as appropriate diagnosis code for this service as per the guidelines. The Plan also says based on documentation 
received, it does not include that the enrollee received the screening study for one of the risk categories as 
listed in the guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that payment may be made for a one-time ultrasound 
screening for AAA for beneficiaries who meet the criteria listed in the Medicare rules section of this letter.  
 
We looked at the file and Medicare rules. Specifically, the record does not show that the enrollee has a family 
history of AAA, has smoked at least 100 cigarettes in their lifetime, or has other risk factors which are 
recommended for screening. Based on this information, we decided that Medicare rules for coverage of the 
ultrasound of the abdominal aorta have not been met. Therefore, we decided that the Plan does not have to pay 
for the ultrasound of the abdominal aorta (76706) provided on September 8, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity (J3111) and the therapeutic, prophylactic, or 
diagnostic injection (96372). 
 
  You asked the Plan to pre-approve Evenity and the therapeutic, prophylactic, or diagnostic injection. You say 
that the enrollee cannot take oral bisphosphonates due to prior history of gastric ulceration. You also say that 
sequential therapy with an osteoanabolic agent like Romosozumab followed by a potent antiresorptive such as 
Denosumab or Zoledronic Acid is the most appropriate course of action. The Plan denied your request. The 
Plan says the enrollee does not meet the Part B Step Therapy requirements for Evenity. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Evenity and the therapeutic, 
prophylactic, or diagnostic injection. Our reviewer says that the enrollee does not meet the criteria for coverage 
for Evenity. Our physician reviewer found the Plan requires a trial of an injectable bisphosphonate (e.g., 
Pamidronate, Zoledronic Acid) before they will approve the requested drug. In this case, the enrollee has not 
tried and failed the required drugs. Our reviewer also found that there is no documentation provided indicating 
that the Plans required drugs would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Evenity and the therapeutic, prophylactic, or diagnostic injection have not been 
met. Therefore, we decided that the Plan does not have to pre-approve Evenity (J3111) and the therapeutic, 
prophylactic, or diagnostic injection (96372).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a comprehensive oral evaluation (D0150), intraoral x-
rays (D0210), prophylaxis (D1110), and a resin-based composite filling on tooth #29 (D2394) provided on 
January 4, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you disagree with the balance you are 
being billed for the dental services received on January 4, 2022. The Plan denied your request. The Plan says 
you are responsible for any charged amount above the Plans cost-sharing amount when your services are 
received from an out-of-network provider. 
 
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. 
 
 You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment for the dental services received on January 4, 2022. 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 pay more for 
a comprehensive oral evaluation (D0150), intraoral x-rays (D0210), prophylaxis (D1110), and a resin-based 
composite filling on tooth #29 (D2394) provided on January 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the dental cleaning (D1110) provided on July 6, 2022. 
 
You asked the Plan to pay more for the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. 
 
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. 
 
 
  You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for the dental cleaning (D1110) provided on 
July 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lower limb prosthetic equipment to be provided to the 
enrollee by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the prosthetic equipment. You say that there are no other providers that have 
this equipment. The Plan denied your request. The Plan says the required equipment can be provided by a 
network provider. 
 
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 
lower limb prosthetic equipment to be provided to the enrollee by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you say that the services are medically necessary. 
You are unable to walk and require physical therapy to be able to go home and take care of your husband. The 
Plan denied your request. The Plan says the services you need can be provided safely in another setting such as 
a skilled nursing facility or home with home health services. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on your medical records there are no documented active medical needs 
showing that you would require an acute hospital inpatient stay with an approach to rehabilitation care. IRF 
criterial is not met 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary, the 
enrollee failed at a lower level of care and is a readmission. The Plan denied your request. The Plan says the 
enrollee is receiving appropriate inpatient acute care and does not require transfer at this time. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee continues to receive acute care services and these have not been denied. 
The medical record does not indicate that the enrollee requires services that they are not currently receiving but 
that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. 
 
 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an endoscopy procedure on the esophagus 
provided on August 24, 2022. 
 
You asked the Plan to waive the copayment for an endoscopy procedure on the esophagus. You say that the 
provider was unclear in explaining the how much the copayment would be and you having difficulty following 
which services were paid. 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 $350 
copayment for outpatient surgery. 
 
You have been asked to pay a $350 copayment for an endoscopy procedure on the esophagus. This 
item/service falls within the outpatient surgery 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 endoscopy procedure on the esophagus provided on August 24, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an physical therapy visit provided on September 26, 2022. 
 
You asked the Plan to pay for an physical therapy visit. You say that this was medically necessary and should 
be covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an physical therapy visit 
provided on September 26, 2022.