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

 
We decided that the Plan does not have to pre-approve dental services provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve the dental services. You say that you have been seeing this dentist for years 
and would like to continue. The Plan denied your request. The Plan says dental services from an out-of-
network provider are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve dental 
services 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 covid-19 testing, and the specimen transportation 
provided from December 21, 2022, to January 4, 2023, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the covid-19 testing and specimen transportation. You say that you do not think 
you should have to pay for these services. The Plan denied your request. The Plan says you must receive your 
care from a network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 covid-19 testing, and the specimen 
transportation provided from December 21, 2022, to January 4, 2023, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eight home health physical therapy visits effective April 
26, 2023, thru May 24, 2023. 
 
You asked the Plan to pre-approve home health services. You say that eight physical therapy visits are 
medically necessary. The Plan denied your request. The Plan says the 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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found there is no 
documentation that the enrollee is home bound or recent clinical/functional status change that would require 
continued physical therapy in home setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve eight home health physical therapy visits effective April 26, 2023, thru May 24, 
2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab testing services billed for date of service October 28, 2022. 
 
You asked the Plan to pay for the billed services. You say that the ordering provider found it medically 
necessary to perform the tests. The Plan denied your request. The Plan says that the unique identifier was not 
billed as required. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. A review of the claim does show that the required unique identifier 
was reported. The Plan has not made reasonable and diligent efforts to gather and forward to us information 
regarding their decision to deny your request.  Therefore, we decided that the Plan has to pay for the lab testing 
services billed for date of service October 28, 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 pre-approve a complete mandibular and maxillary overdenture 
(D5865), and the repair of soft/hard tissue (D7955). 
 
You asked the Plan to pre-approve the dental services. You say that this dental work is needed. The Plan denied 
your request. The Plan says the requested dental services are not covered benefits. 
 
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 
complete mandibular and maxillary overdenture (D5865), and the repair of soft/hard tissue (D7955).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator, any type, used with non-invasive 
interface (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that without the non-invasive ventilator, the enrollee 
will continue to decline. The non-invasive ventilator will improve this enrollee's quality of life. The Plan 
denied your request. The Plan says the request for a home mechanical ventilator set in AVAPS mode with 
Auto-EPAP (AE) that could be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 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 ventilator. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this enrollee has severe COPD and was hospitalized for acute on chronic hypercarbic 
respiratory failure in September 2022.  The enrollee has a history of chronic narcotic use, and the enrollees 
mental status improved at that time with Narcan. The enrollee improved in the hospital on bilevel positive 
airway pressure (BiPAP).  The enrollee has had a home ventilator in the past, but this was replaced with 
BiPAP.  However, the BiPAP has since been recalled and is not being used currently.  This enrollee may 
benefit from BiPAP with average volume-assured pressure support (AVAPS) during sleep as an outpatient.  
There is no evidence that BiPAP is failed as an outpatient.  Medicare does not cover a home ventilator when 
used at settings that can be provided with BiPAP. A home ventilator 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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator, any type, used with non-invasive interface (E0466).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from April 
5, 2022, to April 7, 2022. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that you believe the billing for the 
services is incorrect. 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 $300 
copayment per day for days 1-5 for inpatient hospital care.  
 
 
  The file shows that you were in the hospital from April 5, 2022, to April 7, 2022. Since there is no copayment 
for the discharge date, you have been asked to pay a $300 copayment per day for days 1-2 for the inpatient 
care. The total for your stay is $600 ($300 copayment x 2 days = $600). 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 April 5, 2022, to April 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT). 
 
You asked the Plan to pre-approve PBRT. You say that you have stage 3 pancreatic cancer and without the 
correct treatment, the diagnosis is grim. Proton beam radiation is needed because the head and two veins of the 
tumor are difficult to access. This treatment is needed because precision radiation is required for you to have 
successful reduction of tumor. The Plan denied your request. The Plan says proton beam radiation therapy is 
not the standard of care for the treatment of pancreatic cancer. Standard radiation including intensity-modulated 
radiation therapy is the standard of care. 
 
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 PBRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found standard radiation is delivered with a linear accelerators (LINAC), which deliver photon 
therapy (akin to high energy light), while protons (and other charged particles) are generated from a 
cyclotron.  The difference between proton and photon irradiation is that the protons (or charged particles) stop 
more abruptly in the tissue (Bragg peak) so there is less exit dose through normal tissue. 
 
The use of proton therapy is an accepted radiation technology, that has proven efficacy and tolerability. Proton 
therapy is not investigational- it is simply a different means to deliver radiation. There is a relative paucity of 
data on proton therapy for pancreatic cancer. Most of the recent data are dosimetry studies. 
 
The most recent National Comprehensive Cancer Network (NCCN) guidelines for pancreatic cancer do not 
address proton therapy. The recently released ASTRO model policy acknowledges the need for proton therapy 
when strongly justified by a dosimetric rationale (not provided in this case) such as specific dose-volume 
parameters for the target and nearby structures. In summary, the need for proton therapy is usually established 
with quantitative dosimetric information that shows a clinically meaningful reduction in radiation dose 
exposure of normal tissues. This was not provided for this case. Proton therapy is not supported by consensus 
or expert guidelines Therefore, routine use of proton therapy for unresectable progressive pancreatic cancer is 
not an accepted standard of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve proton beam radiation therapy (PBRT).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for date of service October 19, 
2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the billed code 
cannot be verified. 
 
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 99223 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and medical decision making of high complexity.  
 We find that CPT code 99223 is not supported in the medical record. Specifically, the records do not include a 
comprehensive history for the date of service at issue.. Based on this information, we decided that Medicare 
rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure code 99223 billed for date of service October 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested device is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that the 
documentation does not support that the requested ventilator is medically reasonable or necessary. Our 
physician reviewer found you have chronic respiratory failure from chronic obstructive pulmonary disease. The 
provided primary source documentation does not contain sufficient detailed information in the medical record 
to justify the treatment selected. You could be treated with a bilevel positive airway pressure machine with average volume-assured pressure support; however, capability and failure of such a device has not been 
documented. Therefore, you do not meet criteria for the requested device. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing (80307, G0480) provided on September 10, 
2021. 
 
You asked the Plan to pay for the drug testing. You say that you were understaffed due to the pandemic. The 
Plan denied your request. The Plan says this claim was not filed timely. 
 
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 drug testing was not filed until October 24, 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 the drug testing (80307, G0480) provided on September 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat (E0244). 
 
You asked the Plan to pre-approve a raised toilet seat. You say that you want the Plan to cover this item. The 
Plan denied your request. The Plan says this item is not medical in nature and is not 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 a raised toilet seat (E0244).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a barostim device implantation surgery. 
 
You asked the Plan to pre-approve a barostim device implantation surgery. You say that the service is 
medically necessary. The Plan denied your request. The Plan says the service is not medically 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 a barostim device implantation surgery. 
Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. 
Our physician reviewer found there remains an absence of randomized, blinded clinical studies examining 
long-term clinical outcomes establishing the value of Barostim Neo in patient 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 barostim device implantation surgery have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a barostim device implantation surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal maintenance (D4910). 
 
You asked the Plan to pre-approve periodontal maintenance. You say that the requested periodontal services 
are medically necessary. The Plan denied your request. The Plan says that periodontal maintenance (D4910) is 
not covered by the enrollee's dental benefits. 
 
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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
periodontal maintenance (D4910).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound debridement (11043) provided on November 9, 2022. 
 
You asked the Plan to pay for wound debridement (11043). You say that procedure code 11043 has no global 
period and no other claims have ever been denied for this. The Plan denied your request. The Plan says 
procedure code 11043 billed on this date of service is included within the global surgery package of procedure 
code 11403 billed on date of service November 2, 2022. 
 
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 11043 is debridement, muscle and/or fascia (includes 
epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or less. 
 
We find that CPT code 11043 is not supported in the medical record. Specifically, there is no indication this 
service was unrelated to the procedure performed on November 2, 2022. Based on this information, we decided 
that Medicare rules for coverage of wound debridement (11043) have not been met. Therefore, we decided that 
the Plan does not have to pay for wound debridement (11043) provided on November 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out of network retainer with an orthodontist. 
 
You asked the Plan to pre-approve orthodontics. You say that this is a medical need and would like it covered. 
The Plan denied your request. The Plan says this is not a covered service whether it is in or out of network. 
 
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 an 
out of network retainer with an orthodontist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for periodic oral evaluation - established patient (D0120) 
and prophylaxis - adult (D1110) provided on January 10, 2023. 
 
You asked the Plan to pay more for the dental services. You say that your provider is in-network, so you would 
like your insurance to cover the services you received. The Plan denied your request. The Plan says you are 
responsible for any charged amount above the Plans cost-sharing amount when your services are received 
from an out-of-network provider. 
  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. Enrollees must pay 30% 
coinsurance for covered out-of-network dental services and may be billed by the out-of-network provider for 
any charged amount greater than the payment made by the Plan. 
 
The allowed amount of the covered dental services total $400, resulting in a coinsurance of $120 and Plan 
payment amount of $280. 
 
You may also be asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 
 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to pay more for periodic oral evaluation - established patient (D0120) and 
prophylaxis - adult (D1110) provided on January 10, 2023.