Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve knee orthosis durable medicale equipment (DME) to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve knee orthosis DME. 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 are 
non-emergent and equipment can be provided in-network. 
 
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 
knee orthosis durable medicale equipment (DME) 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 pneumatic compression device (E0652, E0656, 
E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the pneumatic compression 
device is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
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, the record does not show a four week trial of 
conservative treatment as defined by Medicare rules. The provided records did not describe the patient actively 
and aggressively exercising daily as required by coverage rules. Therefore, we decided that the Plan does not 
have to pre-approve a pneumatic compression device (E0652, E0656, E0667).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns (D2740) for tooth #'s 20 and 28. 
 
You asked the Plan to pre-approve the crowns. The Plan denied your request. The Plan says your benefit for the 
requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your annual maximum benefit of $1,000 was exhausted on date of service June 27, 2022. Therefore, we 
decided that the Plan does not have to pre-approve crowns (D2740) for tooth #'s 20 and 28.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on March 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 16, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
March 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power seat elevation system (CPT code E2300), foam 
lumbar pads for solid back corpus, transfer handles, and push handles. 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says these items do not serve a medical need and cannot be covered.  
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 power seat elevation system (CPT code E2300), foam 
lumbar pads for solid back corpus, transfer handles, and push handles.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six occupational therapy visits. 
 
You asked the Plan to pre-approve therapy visits. You say that you need occupational therapy to learn to use 
your left arm and hand so you can learn how to groom, bathe, and dress yourself. The Plan denied your request. 
The Plan says you are likely at the level reasonable to achieve with home occupational therapy. 
 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 therapy visits. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent slow deterioration of the 
enrollee's condition. Our physician reviewer found the requested additional six occupational therapy sessions is 
generally accepted as specific and effective therapy for the patients condition beyond what was approved by 
the health plan. The enrollee was authorized additional occupational therapy but the outcome of this therapy or 
the need for ongoing therapy beyond this cannot be considered medically necessary without documentation of 
the outcome of this therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of therapy visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve six occupational therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional periapical x-ray (D0230) provided on January 
14, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says your benefit for a periapical x-ray has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for a periapical x-ray was exhausted on date of service January 14, 2022. Therefore, we 
decided that the Plan does not have to pay for an additional periapical x-ray (D0230) provided on January 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on March 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that you could not go around in pain because of the 
frequency requirements. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service January 13, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
March 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on February 
14, 2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that this charge should be 
covered. The Plan denied your request. The Plan says the copayment applied is 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 $40 
copayment for each covered visit or consultation in an outpatient location with a specialist. 
 
You have been asked to pay $40 copayment for specialist office visit. Specialist office visits fall within the 
Physician/Practitioner Services, Including Doctors Office Visits benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for specialist office visit provided on February 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) chiropractor. 
 
You asked the Plan to pre-approve an office visit. You say that this out-of-network provider's treatment was 
effective in the past, while the in-network providers are not providing the care you need. The Plan denied your 
request. The Plan says the services have been requested out-of-network and there are in-network providers 
available. 
 
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 
an office visit to be provided by an out-of-network (OON) chiropractor.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the urine PCR panel testing (87799, 87798, 87482 and 87150) provided March 18, 2022.

You asked the Plan to pay for the laboratory services. You say that please review and reprocess the claim following CMS guidance. The Plan denied your request. The Plan says the PCR testing is considered unproven and not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered.

We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the urine PCR panel testing (87799, 87798, 87482 and 87150) provided March 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a biopsy of oral tissue-soft (code D7286), a custom 
abutment (code D6057) and fused porcelain (code D6061). 
 
You asked the Plan to pre-approve the biopsy, custom abutment, and fused porcelain. You say that you would 
like these services approved. The Plan denied your request. The Plan says these services are not covered under 
the enrollee's benefit package. 
 
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 
biopsy of oral tissue-soft (code D7286), a custom abutment (code D6057) and abutment supported porcelain 
fused to metal crown (code D6061).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided March 3, 2022. 
 
You asked the Plan to pay for the dental services. You say that you need more than 2 deep cleanings with 
scaling per year to keep periodontal disease at bay. The Plan denied your request. The Plan says your benefit 
for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service November 23, 2021. 
Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided 
March 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure is medically necessary. 
The Plan denied your request. The Plan says the requested service is experimental and non-covered. 
 
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 Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested procedure is still considered investigational. More studies are needed to 
show safety and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the full amount for local anesthesia (D9215) provided on 
October 19, 2021. 
 
You asked the Plan to pay the full amount for local anesthesia. You say that you are owed the money that you 
paid upfront for your dental services. The Plan denied your request. The Plan says your annual allowance 
amount has been exhausted. 
 
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 record shows your annual allowance has been met and you are responsible for any amount over the 
allowance amount. Though the Plan offers a dental benefit in excess of Medicare coverage, your annual 
allowance has been exhausted. Therefore, we decided that the Plan does not have to pay the full amount for 
local anesthesia (D9215) provided on October 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CPAP Durable Medical Equipment (DME) to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the CPAP DME. 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 are 
non-emergent, DME is only provided out-of-are when it is considered 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 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 
CPAP Durable Medical Equipment (DME) to be provided by 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 services provided on January 20, 2022. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the services are 
not a Medicare benefit for the diagnosis listed on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 In this case, the CPT Code Manual definition of code 82306 is Vitamin D; 25 hydroxy, includes fraction(s), if 
performed. We find that CPT code 82306 is not supported in the medical record. There are insufficient medical 
records to show that the testing was ordered for a covered condition. Screening services used to detect an 
undiagnosed disease is not a Medicare benefit.  
 
The CPT Code Manual definition of code 80050 is a general health panel. We find that this service is not 
covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the testing 
services have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing services 
provided on January 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the office visit. 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 are non-emergent 
and care can be provided in network. 
 
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 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81206 and 81292 provided on 
May 12, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 We find that CPT codes 81206 and 81292 are not supported in the medical record. Specifically, when a 
laboratory assays two or more genes in an enrollee in parallel, those two more genes will be considered part of 
the same panel. A panel constitutes a single procedural code so one code should be submitted for the panel. 
Review of the file does not support that only one code was billed for the panel provided. Based on this 
information, we decided that Medicare rules for coverage of the laboratory services have not been met. 
Therefore, we decided that the Plan does not have to pay for the laboratory services coded 81206 and 81292 
provided on May 12, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to hold you harmless for the fitting of spectacle mounted low vision aids (92354) 
provided on March 1, 2022. 
 
You asked the Plan to pay for the fitting of spectacle mounted low vision aids. You say that the provider 
determined during your exam that you needed a new prescription for you existing glasses. You also say that 
having the new bifocal prescription lenses installed in your frames is not an optional low vision reading aid. 
The Plan denied your request. The Plan says that this service is specifically excluded by Medicare and your 
Health Plan benefits. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the fitting of spectacle mounted low vision aids by a contract provider. The file does not 
show that the Plan provided notice that the fitting of spectacle mounted low vision aids would not be covered. 
The record does not show that you were told this fitting fee would not be covered. Under Medicare rules, this 
means the fitting of spectacle mounted low vision aid is considered approved by the Plan. Therefore, we 
decided that the Plan has to hold you harmless for the fitting of spectacle mounted low vision aids (92354) 
provided on March 1, 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 pay for resin-based composites (D2394 and D2335) provided by a 
participating provider on April 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that you feel like this should be covered. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 12, 2022, on teeth 
#20 and #22. Therefore, we decided that the Plan does not have to pay for resin-based composites (D2394 and 
D2335) for teeth #23 and 24 provided by a participating provider on April 12, 2022.