Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a bone replacement graft on tooth #28 (D7953) 
provided on July 18, 2022. 
 
You asked the Plan to pay more for the replacement graft. You say that your dental allowance has not been 
met. The Plan denied your request. The Plan says that your annual dental allowance 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 dental allowance has been exhausted. 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 bone replacement graft on tooth #28 (D7953) provided on July 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a left heart catheterization. 
 
You asked the Plan to pre-approve a left heart catheterization. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a left heart catheterization. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has not had a stress test or coronary computed tomography 
(CT) angiogram. Guidelines do not support a need for cardiac catheterization in this setting. As a result, at this 
time cardiac catheterization would not be considered medically appropriate and necessary in this enrollees 
clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a left heart catheterization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a left heart catheterization.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral x-ray and oral evaluation (D0210, D0150) 
provided on August 9, 2022. 
 
You asked the Plan to pay 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 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 09/11/2020. Therefore, 
we decided that the Plan does not have to pay for an intraoral x-ray and oral evaluation (D0210, D0150) 
provided on August 9, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs received from January 22, 2022, to 
January 24, 2022. 
 
You asked the Plan to pay for the drugs. You say that this should be paid for. The Plan denied your request. 
The Plan says this drug is usually self-administered. 
 
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 pay for self-administered drugs received 
from January 22, 2022, to January 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services (D2331) provided on August 24, 2020. 
 
You asked the Plan to pay 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 the services denied correctly as the claim was 
filed untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
 
  The record shows that a claim for the dental services was not filed until July 17th, 2022. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for dental services (D2331) provided on August 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0668).  
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no documentation of a trial and failure of the four-week trial of a regular, daily, 
multiple hour home usage of the basic device. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that as the records do not document trial and failure of a standard pneumatic compression pump, then it 
cannot be said that the enrollee has unique characteristics that would indicate a segmented pump over a 
standard pump.  
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a pneumatic compression device (E0652, E0668).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression system pump to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve compression system pump. You say that the records attached support this 
service. The Plan denied your request. The Plan says medically necessary care is available 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 
compression system pump to be provided 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 a home health visit provided on June 28, 
2022, to July 26, 2022. 
 
You asked the Plan to waive the copayment for a home health visit. You say that you have been getting these 
visits since 2021 and this is the first time youre getting a copay for it. 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 $10 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $10 copayment for a home health visit. This item/service falls 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.There is a $10 copayment per visit, you have 2 
visits, therefore the total copayment due is $20 ($10 x 2 = $20). Therefore, we decided that the Plan does not 
have to waive the copayment for a home health visit provided on June 28, 2022, to July 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve external mobile cardiovascular outpatient telemetry 
(MCOT) with electrocardiographic recording.  
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records show that a Zio heart monitor was already performed, results were 
interpreted by the provider, and a treatment plan was developed based on those results. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the patient has a history of documented atrial fibrillation and right bundle branch block, with no 
history of syncope or near-syncope. As such, guidelines would not support a need for MCOT monitoring in this 
setting. In summary, there was insufficient documentation to support the medical necessity for an MCOT 
monitor in this patient's clinical management. 
 
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 external mobile cardiovascular outpatient telemetry (MCOT) with electrocardiographic 
recording.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0656).  
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says based on the additional information available, the request does not meet the Medicare or 
health plan coverage criteria. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the provided records do not document at least four weeks of regular, daily, multiple-hour home 
usage of the basic pump E0650 or E0651 after careful, in-person fitting, training and supervision by a 
technician who is skilled in and who regularly and successfully uses the appliance provided. The criteria are 
not met. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a pneumatic compression device (E0652, E0656).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services with no transport on June 27, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on June 27, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance services with no transport on June 27, 
2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy (PT) services to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve the PT services. You say that this facility was recommended to treat your 
condition. The Plan denied your request. The Plan says the provider is out-of-network and authorization was 
not obtained prior to services being rendered. Network providers are available to render appropriate care. 
 
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 (PT) services to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
October 13, 2021, to October 15, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. You say that you were informed that 
you would not be charged for the second night. 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 $295 
per day for days 1-7 for inpatient hospital care.  
 
 
  The file shows that you were in the hospital for 2 days from October 13, 2021, to October 15, 2021. Since there 
is no copayment for the discharge date, you have been asked to pay $295 per day for days 1-2 for the inpatient 
hospital care, for a total of $590. This item/service falls within the inpatient hospital 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 inpatient hospital care provided from October 13, 2021, to 
October 15, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient therapy to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve outpatient therapy. You say that the records attached support the services. 
The Plan denied your request. The Plan says services can be obtained through an in-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 
outpatient therapy to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home podiatry visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a home podiatry visit. You say that you are home bound and need this 
approved so you can be seen in your home. The Plan denied your request. The Plan says there was no 
preauthorization by a primary care provider (this is different than a referral) for an out-of-network (OON) 
provider or facility, and this was not an emergency. If you would like to see this provider, please ask your PCP 
for a preauthorization for this other provider. Or you could go to one of the other in-network podiatrists who 
are 4 miles from your residence. 
 
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 a home podiatry visit to be provided by an 
out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the spine. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show any non-operative treatment for the low back for at least six 
weeks. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 the MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found that on the most recent 
encounter date (10/28/22), the enrollee did not complain of lower extremity symptoms. Rather, there is 
reference to neck pain, and an MRI exam showing stenosis of the cervical spine was planned. There has been 
no physical therapy yet. On the encounter date of 10/19/22, low back pain was described with bilateral sciatica. 
The neurological exam was negative. The plan was for chiropractic referral, none was done. No plain films of 
the lumbar spine have been done. Absent any red flags, the medical necessity of the requested MRI has not 
been established in the provided records. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the spine.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the addition, endoskeletal system, above knee or hip 
disarticulation, alignable system (L5920) and addition to lower extremity, below knee/above knee, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, not for use with 
locking mechanism (L5679x4). 
 
You asked the Plan to pre-approve the alignable system and extra socket inserts. You say that please reconsider 
approval of these two components so that the enrollee can get back to the activities once safely enjoyed. The 
Plan denied your request. The Plan says the request for an alignable system and extra socket inserts exceeds the 
enrollee's needs and do not meet the Medicare criteria of reasonable and necessary. 
 
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 alignable system and extra socket 
inserts. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the requested items exceed the enrollee's medical need as 
the enrollees approved socket includes the L5920 which does not appear to be damaged beyond repair. Per 
documentation L5673 x2 was approved on prior review. L5679 x4 was requested. Per LCD Lower Limb 
Prostheses (L33787): "No more than two of the same socket inserts (L5654, L5655, L5656, L5658, L5661, 
L5665, L5673, L5679, L5681, L5683) are allowed per individual prosthesis at the same time." The request for 
L5979 x4 exceeds the enrollee's need and is 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 alignable system and extra socket inserts have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the addition, endoskeletal system, above knee or hip 
disarticulation, alignable system (L5920) and addition to lower extremity, below knee/above knee, custom 
fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, not for use with 
locking mechanism (L5679x4).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vacuum assisted suspension system. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the use 
is unproven and not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that lower limb prostheses are only covered under certain 
medical indications.  
 
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 requested services. Our physician 
reviewer found that a replacement lower extremity prosthesis with K2 level parts has been approved. The 
requested device has not been shown to be superior to other standard treatments for the medical condition. 
Therefore, the requested device is 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a vacuum assisted suspension system.