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

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the requested  
out-of-network provider. 
 
You asked the Plan to pre-approve physician's services to be provided by the requested out-of-network 
provider. You say that you did not have a pain doctor in Colorado and this physician is the best pain 
management physician. The Plan denied your request. The Plan says you must receive care from in-network 
providers with the exception of emergency or urgent care, dialysis while temporarily out of the Plan's service 
area or if the care cannot be provided with an in-network provider, which requires prior authorization from the 
Plan. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by the requested out-of-network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic exercises (97110) provided on May 3, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for therapeutic exercises. You say that a claim for a different date of service, 
February 18, 2021, for the same procedure code (97110) was partially paid. You also say that the member 
received medically necessary services by your clinic, and you understand you are out-of-network. The Plan 
denied your request. The Plan says this provider is out-of-network with the Plan, and authorization was not 
obtained prior to the services being rendered.  
 The Plan also says that regarding the appellant's statement that the Plan paid for similar services rendered on 
February 18, 2021, they reviewed their records and determined that the date of Services, February 18, 2021, 
was paid due to an administrative error. 
 
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 therapeutic exercises (97110) provided on May 3, 
2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (80307, G0483) provided on August 13, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for drug testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the non-urgent services are not authorized because the provider is a non-network provider with the Plan, and another non-network provider with the Plan referred the member for services.
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 (80307, G0483) provided on August 13, 2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for speech/hearing therapy (92507) provided on May 4, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for speech/hearing therapy. You say that a claim for a different date of service, 
February 5, 2021, for the same procedure code (92507) was partially paid. You also say that the member 
received medically necessary services by your clinic, and you understand that you are out of network. The Plan 
denied your request. The Plan says this provider is out-of-network with the Plan, and authorization was not 
obtained prior to the services being rendered. The Plan also said that regarding the appellant's statement that the 
Plan paid for similar services on February 5, 2021, they reviewed their records and determined that the claim 
for services rendered on February 5, 2021, was denied for no authorization, and the claim was not paid. 
 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 speech/hearing therapy (92507) provided on May 
4, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740), prefabricated post and core in 
addition to crown (D2954), and endodontic therapy (D3330). 
 
You asked the Plan to pre-approve the crown, prefabricated post and core, and endodontic therapy. You say 
that you thought the Plan covered these services. You also say that you cannot afford to pay them out of 
pocket. The Plan denied your request. The Plan says these services are not covered under your 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 pre-approve a 
crown (D2740), prefabricated post and core in addition to crown (D2954), and endodontic therapy (D3330).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (80307, 82542, 84228, G0480) 
rendered by the out-of-network (OON) provider on November 8, 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 (80307, 82542, 84228, G0480) rendered by the out-of-
network (OON) provider on November 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110). 
 
You asked the Plan to pre-approve the dental item. You say that you do not have money to pay $1,450 for a 
new denture. The Plan denied your request. The Plan says the frequency limit for an upper denture has been 
exceeded. 
 
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 and upper dentures are listed as 
covered, the frequency limit of one every 5 years has been reached. The record shows that you received an 
immediate upper denture on March 22, 2019. 
 
Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor and supplies. 
 
You asked the Plan to pre-approve a continuous glucose monitor and supplies. You say that a continuous 
glucose monitor and supplies is medically necessary. The Plan denied your request. The Plan says you do not 
meet all of the required coverage criteria. 
 
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. 
 
 Based on the records provided, you do not meet all of the Medicare criteria for this request. Therefore, we 
decided that the Plan does not have to pre-approve a continuous glucose monitor and supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusions (99601 and 99602) provided on April 29, 
2021. 
 
You asked the Plan to pay for the home infusions (99601 and 99602). You say that you are a DME provider 
and drugs that require administration via covered DME are to be billed to Medicare Part B. You say that the 
attached documents support this, and the claim should be reprocessed for payment of the drug charges. The 
Plan denied your request. The Plan says the billed codes are not valid 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 CPT code. 
 
 
  In this case, the CPT Code Manual definition of code 99601 is home infusion/specialty drug administration, per 
visit (up to 2 hours). The CPT Code Manual definition of code 99602 is home infusion/specialty drug 
administration, per visit (up to 2 hours); each additional hour (List separately in addition to code for primary 
procedure). 
 
We find that CPT codes 99601 and 99602 are not supported in the medical record. Specifically, CPT codes 
99601 and 99602 have a status indicator of I. This means that CPT codes 99601 and 99602 are not valid for 
Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home 
infusions (99601 and 99602) have not been met. Therefore, we decided that the Plan does not have to pay for 
the home infusions (99601 and 99602) provided on April 29, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve physician services from your requested primary care provider. 
 
You asked the Plan to pre-approve the physician services. You say that this is the only contracted primary care 
provider (PCP) at the enrollee's living facility. The Plan denied your request. The Plan says that this provider is 
not contracted as a PCP. 
 
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 provider is in network and the Plan has not offered an alternative provider. 
Therefore, we decided that the Plan has to pre-approve physician services from your requested primary care 
provider.  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve physical therapy services. You say that the enrollee has seen this provider 
before. The Plan denied your request. The Plan says the services have been requested from 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 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 
physical therapy services 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 pre-approve a power seat elevation feature (E2300). 
 
You asked the Plan to pre-approve the feature. You say that this should be paid for. The Plan denied your 
request. The Plan says this is not a covered benefit, and does not serve a primarily medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item 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 power seat elevation feature (E2300).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve the left-sided balloon dilation of the eustachian tube. 
 
You asked the Plan to pre-approve balloon dilation of the eustachian tube. You say that this procedure is 
medically reasonable and necessary. The Plan denied your request. The Plan says that this procedure is 
considered experimental/investigational. 
 
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 balloon dilation of the eustachian tube 
(BDET). Our reviewer says that the requested items/services are considered medically reasonable and 
necessary in this case. Our physician reviewer found Based on available clinical documentation, the requested 
services for left-sided BDET meet criteria for being medically necessary and reasonable. There is no gold 
standard treatment for eustachian tube dysfunction (ETD), including medical therapy. The first device for 
BDET was approved by the US Food and Drug Administration in 2016. Recent systematic reviews reported 
that BDET complications were generally few, mild, and self-limited and that BDET was associated with 
improvement in subjective and objective outcomes for patients with ETD. The American Academy of 
Otolaryngology-Head and Neck Surgery Foundation 2019 clinical consensus statement on BDET concluded 
that BDET was an alternative to tympanostomy tube placement for obstructive ETD and that myringotomy 
with or without tympanostomy tube placement was not a mandatory prerequisite to BDET. The patient had 
persistent symptoms suggestive of left-sided ETD, including aural fullness and subjective hearing loss, despite 
previous medical therapy such as antihistamine nasal sprays and oral steroids. He underwent nasal endoscopy 
that showed no evidence of extrinsic obstruction at the nasopharyngeal orifice of the ETD. In summary, the 
requested BDET meets criteria for being medically necessary and reasonable to treat the patients ETD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of balloon dilation of the eustachian tube have been met. Therefore, we decided 
that the Plan has to pre-approve the left-sided balloon dilation of the eustachian tube.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a panniculectomy (15830). 
 
You asked the Plan to pre-approve the panniculectomy. You say that this procedure is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that panniculectomy is covered when it is performed to 
alleviate such complicating factors as inability to walk normally, chronic pain, ulceration created by the 
abdominal skin fold, or intertrigo dermatitis (dermatitis occurring on opposed surfaces of the skin, skin 
irritation, infection or chafing). 
 
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 panniculectomy. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the record does not indicate 
complicating factors from the pannus. The record as provided is insufficient to establish medical necessity. 
 
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 panniculectomy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a panniculectomy (15830).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Visco-3. 
 
You asked the Plan to pre-approve Visco-3. You say that you would like reconsideration because the Visco-3 is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet step therapy 
exception criteria 
 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 Visco-3. Our reviewer says that the 
enrollee has not trialed viscosupplemental treatments such as Orthovisc, Synvisc and Synvisc-One.  Step 
therapy, as outlined by the plan, requires that these be trialed first. Our physician reviewer found the 
documentation does not outline contraindications or reasons these medications were not considered or that the 
Plan's 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 Visco-3 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Visco-3.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair tie downs for the enrollee. 
 
You asked the Plan to pre-approve the tie downs. You say that this was medically necessary. The Plan denied 
your request. The Plan says these items do not serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item 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 wheelchair tie downs for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the esophagogastroduodenoscopy (EGD) services provided 
on November 18, 2020, billed with codes 43259 and 43239. 
 
You asked the Plan to pay for the EGD services as billed. You say that this was medically necessary and should 
be reimbursed. The Plan denied your request. The Plan says the billed codes are not supported by the records. 
 
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 43259 is Esophagogastroduodenscopy, flexible, transoral; 
with endoscopic ultrasound examination, including the esophagus, stomach, and either the duodenum or a 
surgically altered stomach where the jejunum is examined distal to the anastomosis. The definition of 42239 is 
Esophagogastroduodenscopy, flexible, transoral; with biopsy, single or multiple. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the EGD services as billed. Our reviewer says that the billed codes are not supported. Our reviewer found the documentation submitted does not include any description of 
these services. As such, the billed codes cannot be confirmed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the EGD services as billed have not been met. Therefore, we decided that the 
Plan does not have to pay for the esophagogastroduodenoscopy (EGD) services provided on November 18, 
2020, billed with codes 43259 and 43239.