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

 
We decided that the Plan does not have to pay more for an extraction (D7210) for tooth #19 and to pay for the 
periodontal scaling and root planing (D4341) provided on March 21, 2023. 
 
You asked the Plan to pay more for the dental services. You say that the enrollee went to see a dentist to get a 
deep cleaning and you do not understand why the service is quarterly. The Plan denied your request. The Plan 
says the enrollee's benefit for the first quarter of 2023 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 the Plan paid $625 for dental services on March 21, 2023; therefore, the enrollees benefit for the first 
quarter of 2023 was exhausted on the date of service of March 21, 2023. Therefore, we decided that the Plan 
does not have to pay more for an extraction (D7210) for tooth #19 and to pay for the periodontal scaling and 
root planing (D4341) provided on March 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical nutrition therapy services provided on May 9, 2023. 
 
You asked the Plan to pay for medical nutrition therapy services. You say that you are requesting 
reconsideration for the denied claim. The Plan denied your request. The Plan says it is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the 
Plan does not have to pay for medical nutrition therapy services provided on May 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oral sleep appliance to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve an oral sleep appliance to be provided by an OON provider. You say that 
the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are 
able to provide these services. Therefore, coverage criteria have not been met. 
 
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 oral sleep appliance 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 lab services (0013M) provided on January 23, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare has reaffirmed non-coverage for 
CxBladder, codes 0012M and 0013M. 
 
We looked at the file and Medicare rules. The billed code is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the 
Plan does not have to pay for lab services (0013M) provided on January 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the thoracic-lumbar-sacral orthosis (TLSO) provided on June 
19, 2023. 
 
You asked the Plan to pay for the TLSO. You say that you disagree with the plan's denial. The Plan denied 
your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
 The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. Review of the file shows that the medical records do not include documentation regarding this 
back brace item. The record shows that the Plan made several attempts to obtain the necessary documentation 
without success. Therefore, we decided that the Plan does not have to pay for the thoracic-lumbar-sacral 
orthosis (TLSO) provided on June 19, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on April 3, 2023. 
 
You asked the Plan to pay for psychotherapy. You say that the counseling center confirmed this provider was 
in-network. The Plan denied your request. The Plan says this provider is not credentialed to see Medicare 
patients. 
 
The Plan must follow Medicare rules. Medicare rules say that a Licensed Professional Counselor is not 
eligible to participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Licensed Professional 
Counselor. Medicare says that a Licensed Professional Counselor is not eligible to participate in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for psychotherapy provided on  
April 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve massage therapy sessions to be provided by an out-of-
network provider. You asked the Plan to pre-approve massage therapy sessions. You say that you are requesting reconsideration 
of the denied authorization. The Plan denied your request. The Plan says massage therapy is not covered by 
Medicare. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pre-approve massage therapy sessions to be provided by an out-of-
network provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea.  
You asked the Plan to pre-approve Eylea. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Eylea. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has age-related macular degeneration. The documentation does not support that the enrollee 
has tried and failed bevacizumab. The documentation does not support that bevacizumab would likely be less 
effective and/or likely have adverse effects for the enrollee. Therefore, the enrollee does not meet criteria for 
the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on March 14, 2023. 
 
You asked the Plan to pay for psychotherapy. You say that the counseling center confirmed this provider was 
in-network. The Plan denied your request. The Plan says this provider is not credentialed to see Medicare 
patients. 
 
The Plan must follow Medicare rules. Medicare rules say that a Licensed Professional Counselor is not 
eligible to participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Licensed Professional 
Counselor. Medicare says that a Licensed Professional Counselor is not eligible to participate in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for psychotherapy provided on  
March 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an integrated biopsychosocial assessment provided on 
February 28, 2023. 
 
You asked the Plan to pay for an integrated biopsychosocial assessment. You say that you are requesting 
reconsideration for the denied claim. The Plan denied your request. The Plan says the provider is not 
credentialed to see Medicare patients. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare payment cannot be made to a provider 
that is not enrolled in the Medicare program. The rules also say that LPCs are not eligible to enroll in Medicare.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an integrated biopsychosocial assessment have not been met. Therefore, we decided that the Plan 
does not have to pay for an integrated biopsychosocial assessment provided on February 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) testing provided 
on June 22, 2023. 
 
You asked the Plan to pay for the urine PCR testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services provided are 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 pay for the urine PCR testing. 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 a long-standing history of urinary incontinence and a history of 
several interventions (slings, Botox) for it. The evaluation for urinary tract infection with urinalysis and 
culture/sensitivity is appropriate. PCR testing is not indicated based on the documentation. Therefore, the 
enrollee did not meet criteria for the services rendered. 
 
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 urine PCR testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the urine polymerase chain reaction (PCR) testing provided on June 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 26, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on May 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee is compliant with bilevel 
positive airway pressure (BIPAP) and average volume-assured pressure support (AVAPS) may be delivered 
with BIPAP to continue to treat the enrollee. Arterial blood gas analysis (ABG) show improvement and per the 
documentation the enrollee is complaint with therapies. Hence, there is no indication for a home ventilator for 
therapy that may be delivered by BIPAP, at this junction of the enrollee's 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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nebulizer provided on May 22, 2023. 
 
You asked the Plan to pay for nebulizer. You say that you are requesting reconsideration for the denied claim. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for nebulizer provided on 
May 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay the full cost for the chiropractic manipulative treatment (98941), 
ultrasound therapy (97035) and electric stimulation therapy (97014) provided on June 6, 2023. 
 
You asked the Plan to pay the full cost for the chiropractic manipulative treatment (98941), ultrasound therapy 
(97035) and electric stimulation therapy (97014). You say that these treatments minimize the pain in your 
nerves, joints and muscles. You say that you are appealing for complete coverage. The Plan denied your 
request. The Plan says the chiropractic manipulative treatment processed correctly with a $20 copayment and 
the remaining services are denied as they are not a covered chiropractic service.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. 
 
You have been asked to pay a $20 copayment for the chiropractic manipulative treatment (98941). This service 
falls within the Chiropractic Services benefit category. In addition, the ultrasound therapy (97035) and electric 
stimulation therapy (97014) remain denied as they are not a covered chiropractic service. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. Therefore, we decided that the 
Plan does not have to pay the full cost for the chiropractic manipulative treatment (98941), ultrasound therapy 
(97035) and electric stimulation therapy (97014) provided on June 6, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Prometheus Anser IFX test provided on May 23, 2022. 
 
You asked the Plan to pay for the Prometheus Anser IFX test. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says that the services rendered were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the Prometheus Anser IFX test. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found the enrollee has a diagnosis of Crohn's Disease. Therefore, the enrollee met 
criteria for the services rendered. 
 
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 Prometheus Anser IFX test have been met. Therefore, we decided that the 
Plan has to pay for the Prometheus Anser IFX test provided on May 23, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foodcare services provided on November 22, 2022. 
 
You asked the Plan to pay for foodcare services. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for foodcare services 
provided on November 22, 2022.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance service, basic life support, non-emergency transport, and 
ground mileage provided on September 3, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that the ambulance transport services were 
medically necessary and therefore payable.  The Plan denied your request. The Plan says that  the ambulance 
transport services were not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 pay for the ambulance services. Our reviewer says 
that the ambulance services were medically necessary. Our physician reviewer found the enrollee is morbidly 
obese and required more than one person for safe transport. The enrollee is unable to stand or sit for prolonged 
periods and is a fall risk. The enrollee has a cardiac history and is noted to have a colostomy bag. The 
documentation supports that the ambulance transport services were medically reasonable and 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 ambulance services have not been met. Therefore, we decided that the Plan 
has to pay for ambulance service, basic life support, non-emergency transport, and ground mileage provided on 
September 3, 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services provided on June 20, 2023. 
 
You asked the Plan to pay for the psychotherapy services. You say that you are being billed for these services. 
The Plan denied your request. The Plan says these services were received from ineligible provider. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
A review of the case file and Medicare records indicates that the provider at issue is not enrolled in the 
Medicare program. Therefore, we decided that the Plan does not have to pay for the psychotherapy services 
provided on June 20, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy services provided on June 
05, 2023, to June 28, 2023. 
 
You asked the Plan to waive the copayment for physical therapy services. You say that you feel that you should 
not have to pay the copayments. 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 $210 
copayment for Outpatient rehabilitation services. 
 
You have been asked to pay a $210 copayment for physical therapy services. This item/service falls within the 
Outpatient rehabilitation 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. The enrollee must pay a $35 copayment per day for Medicare covered physical 
therapy services ($35 x 6 = $210). Therefore, we decided that the Plan does not have to waive the copayment 
for physical therapy services provided on June 05, 2023, to June 28, 2023.