Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on July 4, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that the claim is billed correctly and should be paid. 
The Plan denied your request. The Plan says this is a non-covered service. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on July 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 06, 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 July 06, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the powered upper extremity motion assist device to be 
provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the motion assist device. You say that this item is medically necessary. The 
Plan denied your request. The Plan says enrollees must receive their 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 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 item/service at issue in this appeal. We found no exception that would require 
the Plan to pre-approve this item/service. Therefore, we decided that the Plan does not have to pre-approve the 
powered upper extremity motion assist device 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 provided on June 28, 2023. 
 
You asked the Plan to pay for the lab services. You say that this testing is medically necessary and should be 
covered. The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on June 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on July 24, 2023. 
 
You asked the Plan to pay for practitioner 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 practitioner services 
provided on July 24, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the over-the-counter (OTC) COVID-19 test (K1034) 
provided on June 26, 2023. 
 
You asked the Plan to pay for the OTC COVID-19 test. You say that you would like the clam to be processed 
towards payment. The Plan denied your request. The Plan says OTC COVID-19 tests, K1034, are not covered 
by Medicare after May 11, 2023. 
 The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items, including self-
administered COVID-19 tests and the OTC COVID-19 test is an OTC item. Therefore, we decided that the 
Plan does not have to pay for the over-the-counter (OTC) COVID-19 test (K1034) provided on June 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0013M) provided on May 15, 2023. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for Cxbladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder test have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cxbladder test (0013M) provided on May 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office services provided on January 17, 2023. 
 
You asked the Plan to pay for office 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 office services provided 
on January 17, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone density test provided on May 04, 2023. 
 
You asked the Plan to pay for a bone density test. You say that the services were medically necessary. 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 a bone density test 
provided on May 04, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided 
September 8, 2022, to September 27, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that you request reconsideration based 
on medical necessity for this enrollee and evidence based medical literature that substantiate the efficacy of the 
treatment rendered. The Plan denied your request. The Plan says claims for E0675 will be denied as not 
reasonable and necessary. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) provided September 8, 2022, to September 27, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service June 18, 
2023, to July 15, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that these services were medically necessary and 
were ordered by an in-network provider. The Plan denied your request. The Plan says the billed code is invalid 
for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service June 18, 2023, to July 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental cleaning (D1110) and the periodic oral evaluation 
(D0120) provided on June 22, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says the dental services were received from 
an out-of-network provider and are not covered under the supplemental dental policy.  
 
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 that the enrollee received the dental services from an out-of-network provider. Though the 
Plan offers a dental benefit in excess of Medicare coverage, dental 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 pay for 
the dental cleaning (D1110) and the periodic oral evaluation (D0120) provided on June 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on August 10, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that the claim is billed correctly and should be paid. 
The Plan denied your request. The Plan says this is a non-covered service. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on August 10, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of an interspinous stabilization device 
(22869). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested 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 this service. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that interspinous process stabilization devices are experimental. More research is needed. 
 
  
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the insertion of an interspinous stabilization device (22869).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral device (E0486) provided on July 11, 2023. 
 
You asked the Plan to pay for the oral device (E0486). You say that you were able to receive the item faster 
through this provider. 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 the oral device (E0486) 
provided on July 11, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the injection, lecanemab-irmb, 1 mg (Leqembi) (J0174). 
 
You asked the Plan to pre-approve the medication. You say that Leqembi (J0174) is medically necessity for the 
enrollee's treatment for Alzheimer's disease.  The Plan denied your request. The Plan says the use of Leqembi 
is not reasonable and necessary for this enrollee. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise 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 the medication. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the review indicates that the enrollee has not undergone a neurocognitive evaluation within the 
past 3 months with a Mini Mental State Examination (MMSE) score between 22-30 and/or a Montreal 
Cognitive Assessment (MoCA) score between 17-30, and apolipoprotein E4 (ApoE e4) status test results has 
not been submitted. The review has determined that the documentation does not support that the Leqembi is 
medically reasonable and necessary for the enrollee. The documentation does not support that the Leqembi is 
safe and effective for the enrollee. 
 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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the injection, lecanemab-irmb, 1 mg (Leqembi) (J0174).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a toilet rail. 
 
You asked the Plan to pre-approve a toilet rail. You say that the item is necessary. The Plan denied your 
request. The Plan says the requested item is not primarily medical in nature. 
 
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 toilet rail.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planning (D4341) for the 
upper left, lower left and lower right quadrants. 
 
You asked the Plan to pre-approve the dental services. You say that D4341 for all four quadrants is necessary 
due to the periodontal pockets and bone loss. The Plan denied your request. The Plan says the procedure 
submitted may be more accurately represented by another dental code. 
 
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 Plan covers the dental 
services when the services are medically necessary and reasonable.  
 
 
  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 dental services. Our reviewer says 
that the request is not medically necessary. Our physician reviewer found that the periodontal record is not 
complete and there is no documentation of any bleeding on probing which would indicate inflammation of the 
gum tissues. The full mouth series of x-rays included is not of diagnostic quality. The bone levels and if there is 
any tarter underneath the gums cannot be assessed. Due to the missing information from the periodontal 
charting record and the undiagnostic x-rays, D4341 is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve periodontal scaling and root planning (D4341) for the upper left, lower left and lower 
right quadrants.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint 
nerve(s) with imaging guidance (fluoroscopy or CT); cervical or thoracic facet joint (64633, 64634). 
 
You asked the Plan to pre-approve cervical region radiofrequency ablation (RFA). You say that this is 
medically necessary. The Plan denied your request. The Plan says no more than two radiofrequency sessions 
will be reimbursed per rolling 12 months. 
 
The Plan must follow Medicare rules. Medicare rules say that for each covered spinal region no more than two 
(2) radiofrequency sessions will be reimbursed per rolling 12 months. We looked at the file and Medicare rules. The record shows that RFA has been performed twice in this region 
within the last 12 months. The Plan has confirmed they paid for the RFA received on March 27, 2023 and April 
10, 2023. Based on this information, we decided that Medicare rules for coverage of cervical region 
radiofrequency ablation (RFA) have not been met. Therefore, we decided that the Plan does not have to pre-
approve destruction by neurolytic agent, paravertebral facet joint nerve(s) with imaging guidance (fluoroscopy 
or CT); cervical or thoracic facet joint (64633, 64634).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for positron emission tomography (PET) scan 
provided on July 17, 2023. 
 
You asked the Plan to waive the copayment for positron emission tomography (PET) scan. You say that you 
can not afford the copayment, it is too high. 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 $225 
copayment for outpatient diagnostic tests and therapeutic services andsupplies. 
 
You have been asked to pay a $225 copayment for positron emission tomography (PET) scan. This 
item/service falls within the outpatient diagnostic tests and therapeutic services andsupplies 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 positron emission tomography (PET) scan provided on July 
17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
December 20, 2022, and billed with codes 87640, 87481, 87798, and 87653. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR panel have not been met. 
Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel 
provided on December 20, 2022, and billed with codes 87640, 87481, 87798, and 87653.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided on February 27, 2023. 
 
You asked the Plan to pay for anesthesia services. You say that the services were medically necessary. 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 anesthesia services 
provided on February 27, 2023.