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

 
We decided that the Plan does not have to pre-approve the CxBladder Monitor testing provided on September 
16, 2021. 
 
You asked the Plan to pre-approve the CxBladder Monitor testing. You say that this is a medically necessary 
test. The Plan denied your request. The Plan says this test is not covered by Medicare. 
 
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 CxBladder Monitor testing. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the enrollee is a male with reported bladder cancer, unspecified. No other 
clinical information was provided in the records.  
 
CxBladder is considered experimental/investigational as a screening test for urothelial cancer. Cystoscopy, 
ureteroscopy, possible biopsy and upper tract imaging will still be necessary regardless of the results of 
Cxbladder testing. Urinary biomarker tests such as CxBladder give significant false-negative results in patients 
with urothelial cancer and are subject to false-positive results in others. Accuracy is poor for low-stage and 
low-grade tumors.   
 
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 CxBladder Monitor testing have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the CxBladder Monitor testing provided on September 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sales tax (D9985) provided by an out-of-network provider on 
December 20, 2021. 
 
You asked the Plan to pay for sales tax. You say that all you had was your teeth cleaned. The Plan denied your 
request. The Plan says D9985 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 pay for sales tax 
(D9985) provided by an out-of-network provider on December 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  the pneumatic compression device (E0676), provided on 
August 18, 2021. 
 
You asked the Plan to pay for  the pneumatic compression device. You say that the item is medically necessary. 
The Plan denied your request. The Plan says A PCD that provides intermittent limb compression for the 
purpose of prevention of venous 
thromboembolism (E0676) is a preventive service. Items that are used for a preventative service or function are 
excluded from coverage under the Medicare DME benefit. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for  the pneumatic compression device (E0676), provided on August 18, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Fentanyl. 
 
You asked the Plan to pre-approve Fentanyl. You say that the medication is necessary. The Plan denied your 
request. The Plan says your plan does not have a Medicare Part D benefit, or a separate pharmacy benefit 
managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Fentanyl.  
 
Benefits for Fentanyl 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee brace (L1851) and suspension sleeve (L2397), 
provided on November 1, 2021. 
 
You asked the Plan to pay for the knee brace and suspension sleeve. You say that the items are medically 
necessary. The Plan denied your request. The Plan says there was no documentation submitted to show medical 
necessity for these items. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the knee brace (L1851) and suspension 
sleeve (L2397), provided on November 1, 2021. have been met. the documentation does not include relevant 
medical records to show that Medicare criteria for coverage of the orthotics have been met.. Therefore, we 
decided that the Plan does not have to pay for the knee brace (L1851) and suspension sleeve (L2397), provided 
on November 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the determination of refraction state (92015), provided on 
December 28, 2021. 
 
You asked the Plan to pay for the determination of refraction state. You say that the service should be covered. 
The Plan denied your request. The Plan says refractive services are not covered under your benefit plan unless rendered by a Routine Vision Care Provider found in the Routine Vision Care section of the Plans Provider 
Directory. 
 
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 these services when the eye refraction is obtained by a Plan provider. 
 
We looked at the file and the Plan's rules. You did not obtain this service through a Plan provider. Based on this 
information, we decided that the Plan's rules for coverage of the determination of refraction state have not been 
met. Therefore, we decided that the Plan does not have to pay for the determination of refraction state (92015), 
provided on December 28, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve services performed by a qualified physical therapist 
(G0151 x2) and services performed by a qualified occupational therapist (G0152 x6) for the enrollee. 
 
You asked the Plan to pre-approve the home health services. You say that outpatient physical therapy is not 
realistic for the enrollee. The Plan denied your request. The Plan says these services are not medically 
necessary.  
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the requested services are not medically reasonable or necessary. Our physician reviewer found that in 
this case, the documentation doesnt support that the the enrollee requires additional skilled rehab services to 
provide treatment that is medically necessary. The enrollee does not require additional skilled rehab services to 
effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or perform a 
maintenance program to maintain the enrollee's condition and/or prevent deterioration. The enrollee has been 
medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The 
requested home health services are not 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve services performed by a qualified physical therapist (G0151 x2) and services 
performed by a qualified occupational therapist (G0152 x6) for the enrollee.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room visit provided on 
December 9, 2021. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you don't feel as though 
you should have to pay for the copayment because the PCP should have sent you to urgent care instead of the 
ER. The Plan denied your request. The Plan says the $120 copayment applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $120 
copayment for emergency care services. 
 
 
 
 
 
 You have been asked to pay a $120 copayment for an emergency room visit. The emergency room visit falls 
within the Emergency care 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 Emergency 
care services provided on December 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient clinic visit provided on February 2, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient clinic visit. You say that service was provided to the enrollee out 
of medical necessity, and you would like the claim to be reprocessed for payment. The Plan denied your 
request. The Plan says the rendering provider is an out-of-network provider and there was no referral from an 
in-network provider or an approved authorization. Also, the service rendered was not urgent or emergent. 
 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 outpatient clinic visit provided on February 2, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Audiology services on December 9, 2021. 
 
You asked the Plan to waive the copayment for Audiology services. You say that you were advised there would 
be no cost-share for the service. The Plan denied your request. The Plan says the claim was processed correctly 
as billed. 
 
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 $260 
copayment for Audiology services.  
 
 
 
 You have been asked to pay a $260 copayment for Audiology services. Audiology services falls 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 Audiology 
services on December 9, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued physical therapy (PT) services for the 
enrollee. 
 
You asked the Plan to pre-approve the services. You say that you have been treating the patient with 
anticipated progress. The Plan denied your request. The Plan says no visits can be approved. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 services. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the additional requested therapy generally is not accepted as specific 
and effective therapy for the patients condition beyond what was approved by the plan. The patient has had 
prior therapy  and the documentation does not reveal that the patient requires the unique skills of a professional 
therapist to safely and effectively provide treatment, or that the services can be safely and effectively 
performed only by a therapist, or by or under the supervision of a therapist. The patient has 5/5 right knee 
strength, normal range of motion, and unremarkable gait. She can transition to a home exercise program. The 
requested services are not part of a maintenance program and the specialized skill, knowledge and judgment of 
a qualified therapist is not required to establish, design and/or deliver a program to maintain the patient's 
current condition or to prevent or slow further deterioration. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued physical therapy (PT) services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction (92015) provided on December 8, 2021. 
 
You asked the Plan to pay for an eye refraction. You say that you think this should be covered as part of a 
routine eye exam. The Plan denied your request. The Plan says the service at issue is not a covered benefit. 
 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 this service when it is performed as a routine screening by a participating provider. 
 
We looked at the file and the Plan's rules. The eye refraction was performed as part of a medical vision exam, 
and therefore is not a covered benefit. Based on this information, we decided that the Plan's rules for coverage 
of an eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for an eye 
refraction (92015) provided on December 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee brace (L1851) and suspension sleeve (L2397), 
provided on October 21, 2021. 
 
You asked the Plan to pay for the knee brace and suspension sleeve. You say that the items are medically 
necessary. The Plan denied your request. The Plan says these items were obtained through an unsolicited 
telephone call. 
 
The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone 
regarding the furnishing of a covered item except under specific circumstances. 
 
We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an 
unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact 
by telephone regarding the furnishing of this item. The record does not show that contact was initiated 
regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the 
past 15 months. Based on this information, we decided that Medicare rules for coverage of the knee brace and 
suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for the knee 
brace (L1851) and suspension sleeve (L2397), provided on October 21, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the HH PT visits (CPT code G0151 x6). 
 
You asked the Plan to pre-approve the home health physical therapy visits. You say that the services are 
necessary. The Plan denied your request. The Plan says the medical record does not document a clearly evident 
need for the services of a skilled physical therapist. The Plan states you have already been educated on a home 
exercise program and there is no documentation of an active or acute on chronic condition that would 
necessitate a new program. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
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 home health physical therapy visits. 
Our physician reviewer found the health plan's denial should be upheld. You do not have documented skilled 
therapy needs. You are dependent for all mobility and cares, which can be tended to by family, friends or paid 
caregivers. Ongoing HH PT services are not medically necessary or reasonable. 
 
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 home health physical therapy visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the HH PT visits (CPT code G0151 x6).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited re-evaluation (D0170) and post 
and core in addition to crown (D2952), or pay more for the panoramic x-ray (D0330), crown (D2740), and 
endodontic therapy (D3330) provided from September 14, 2021, to December 22, 2021 by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the problem focused limited re-evaluation and post and core, and to pay more for 
the panoramic x-ray, crown, and endodontic therapy. You say that you cannot afford to pay for these services 
and would like them to be approved for coverage. The Plan denied your request. The Plan says the problem 
focused limited re-evaluation and post and core are not covered under the Plan. The Plan also says that the cost 
shares applied correctly for the panoramic x-ray, crown, and endodontic therapy. 
 
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 problem focused limited re-
evaluation (D0170) and post and core in addition to crown (D2952) are not among those covered under this 
benefit. The contract also says that you are responsible for the the difference between the billed amount and 
allowed amount for the covered dental services because they were received OON. Therefore, we decided that 
the Plan does not have to pay for the problem focused limited re-evaluation (D0170) and post and core in 
addition to crown (D2952), or pay more for the panoramic x-ray (D0330), crown (D2740), and endodontic 
therapy (D3330) provided from September 14, 2021, to December 22, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigation (D4921) provided on January 10, 2022. 
 
You asked the Plan to pay for the dental service. You say that you feel that your dental allowance should allow 
the treatment and cover the cost. The Plan denied your request. The Plan says the gingival irrigation 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 gingival irrigation is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the gingival irrigation (D4921) provided on January 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110). 
 
You asked the Plan to pre-approve a complete upper denture. You say that your denture was lost, and you need 
a new one. The Plan denied your request. The Plan says you will exceed the frequency limit for this 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. The Plan covers a complete 
upper denture once every five plan years.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a complete upper 
denture was previously covered on September 29, 2020. Based on this information, we decided that the Plan's 
frequency limit for coverage of a complete upper denture will be exceeded with the requested service. 
Therefore, we decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110).