Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve treatment with Leqvio (J1306). 
 
You asked the Plan to pre-approve Leqvio. You say that Leqvio is a medical necessity for the enrollee. The 
Plan denied your request. The Plan says that the requested drug is not eligible for coverage under Medicare Part 
B in this case. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan's denial states that the requested drug is dispensed by a 
pharmacy and does not represent an expense to the physician. However, the case record documents that your 
office has indicated to the Plan that the requested drug is a "buy and bill," meaning that in this case it does 
represent an expense to the physician. The Plan has not provided documentation to support its assertion that the 
requested drug is dispensed by a pharmacy. It is the Plan's responsibility to support its denial. In this case, the 
Plan's denial is not supported, so we must find in your favor. Therefore, we decided that the Plan has to pre-
approve treatment with Leqvio (J1306).  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care services provided on December 29, 2022. 
 
You asked the Plan to pay for the wound care services. You say that these 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 the wound care services 
provided on December 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided on February 16, 2022, to 
September 28, 2022. 
 
You asked the Plan to pay more for the dental services. You say that these services should be paid in full. 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. 
 
You have been 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 dental services provided on February 16, 
2022, to September 28, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve retainer crown - porcelain/ceramic (D6740) for teeth #17, #21, 
#22, and pontic- porcelain/ceramic (D6245) teeth #18, #19, #20. 
 
 
You asked the Plan to pre-approve retainer crown for teeth # 17,21, and 22 and a pontic for teeth #18,19 and 
20. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not 
medically necessary, teeth 17 and 21 for the retainer crown were denied because they did not have good long-
term outcomes due to decay or infection. For teeth 18, 19, 20, and 22 for the retainer crown and pontic this was 
denied because the treatment plan was denied, and the notes and x-rays did not show medical necessity for the 
treatment. 
 
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 retainer 
crown for teeth # 17,21, and 22 and a pontic for teeth #18,19 and 20 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 retainer crown for teeth # 17,21, and 22 
and a pontic for teeth #18,19 and 20. Our reviewer says that the service is not medically necessary. Our 
physician reviewer found the documentation provided meets the criteria for coverage for a fixed bridge 
replacing missing teeth #'s 18, 19 and 20 with pontics (D6245) using teeth #'s 17 and 22 as abutment retainers 
(D6740). 
 
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 retainer crown for teeth # 17,21, and 22 and a pontic for teeth #18,19 and 20 
have been met. Therefore, we decided that the Plan has to pre-approve retainer crown - porcelain/ceramic 
(D6740) for teeth #17, #21, #22, and pontic- porcelain/ceramic (D6245) teeth #18, #19, #20. 
  
 
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 issue reimbursement for the hearing aids (V5257 x 2) purchased on 
December 20, 2021. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says these items are not payable as 
they were purchased from an out-of-network provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract provides coverage for hearing aids 
only when purchased from the Plans select hearing aid provider. However, the hearing aids in this case were 
purchased from an out-of-network provider. Therefore, we decided that the Plan does not have to issue 
reimbursement for the hearing aids (V5257 x 2) purchased on December 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), dental cleaning 
(D1110), and the bitewing x-rays-four radiographic images (D0274) provided on January 23, 2023. 
 
You asked the Plan to pay for these 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 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. 
 
The record shows you 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 periodic oral evaluation (D0120), dental 
cleaning (D1110), and the bitewing x-rays-four radiographic images (D0274) provided on January 23, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on January 
24, 2022.  
You asked the Plan to waive the copayment for the ambulance transport. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $100 copayment for ambulance services.  
 
You have been asked to pay a $100 copayment for the ambulance transport. This service falls within the 
ambulance services benefit category. This means that you have been asked to pay the correct amount based on 
the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon 
enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance 
transport provided on January 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that a CGM is medically necessary. The Plan denied your 
request. The Plan says the medical criteria for a CGM have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 2 
continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a diagnostic mammogram and a breast ultrasound provided 
on August 15, 2022, by an OON provider. 
 
You asked the Plan to pay for the mammogram and ultrasound. You say that you are asking for reconsideration 
of the denial claim. The Plan denied your request. The Plan says that these services were not authorized. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the enrollee can receive care from out-of-network provider for certain covered services. The Plan 
contract also says that outpatient diagnostic testing and therapeutic services are not covered out-of-network. 
 
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 a diagnostic mammogram and a breast ultrasound 
provided on August 15, 2022, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental office visits to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the dental office visits. You say that this office is very close to your home, 
you have handicap parking and the staff helps you. You also say that you are praying you will honor the  dental 
appointment. The Plan denied your request. The Plan says a network search has been conducted and there are 
contracted healthcare professionals available to see you. 
 
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 
dental office visits 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 pay for the vision services provided on December 02, 2022. 
 
You asked the Plan to pay for the vision services. You say that you disagree with the denial of this 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 the vision services 
provided on December 02, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided from September 28, 2021, to 
October 6, 2021. 
 
You asked the Plan to pay for the nursing facility care. You say that the claim was filed timely. The Plan 
denied your request. The Plan says the provider did supply evidence that claim was attempted to be billed once 
before, but provider failed to re-file claim within timely file, despite being timely notified of rejection of initial 
claim. 
 
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 nursing facility care was not filed until January 18, 2023. 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 nursing facility care provided from September 28, 2021, to 
October 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a leadless pacemaker (33274). 
 
You asked the Plan to pre-approve a leadless pacemaker. 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. Medicare rules say that CMS covers leadless pacemakers when 
procedures are performed in Food and Drug Administration (FDA) approved studies. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a leadless pacemaker have not been met. Therefore, we decided that the Plan does not have to pre-
approve a leadless pacemaker (33274).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant Reveal laboratory testing provided on October 16, 
2022, billed with code 81479. 
 
You asked the Plan to pay for Guardant Reveal. You say that you are the only provider for this service. The 
Plan denied your request. The Plan says the claim for this molecular pathology testing did not include the 
required unique identifier. 
 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. Review of the claim shows that the required unique identifier has 
been reported on the claim. However, the DEX Registry shows this test has a coverage status of not covered. 
Based on this information, we decided that Medicare rules for coverage of Guardant Reveal have not been met. 
Therefore, we decided that the Plan does not have to pay for Guardant Reveal laboratory testing provided on 
October 16, 2022, billed with code 81479.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns-porcelain/ceramic (D2740) for tooth #28 and 
#29. 
 
You asked the Plan to pre-approve the crowns. You say that you are requesting reconsideration for the denial 
of dental crowns. The Plan denied your request. The Plan says the service is not medically necessary. 
 
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. 
 
 
 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 crowns. Our reviewer says that the 
service does not meet the criteria for coverage. Our physician reviewer found a review of the documentation 
indicates the presence of crowns on tooth #28 and #29. These crowns appear adequate and there is no narrative 
indicating why these crowns need replacing. The documentation provided does not meet the criteria for 
coverage for replacement crowns (D2740) for tooth #28 and #29. 
 
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 crowns have not been met. Therefore, we decided that the Plan does not 
have to pre-approve crowns-porcelain/ceramic (D2740) for tooth #28 and #29.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an annual routine physical exam provided on 
December 1, 2022. 
 
You asked the Plan to pay for the annual routine physical exam. The Plan denied your request. The Plan says 
benefit maximum for this time period or occurrence has been reached. 
 
The Plan contract covers one annual routine physical exam per calendar year. 
 
We looked at the file and the Plans rules. The file shows that you received an annual routine physical exam on 
March 31, 2022. The benefit maximum for this time period or occurrence has been reached. Therefore, we 
decided that the Plan does not have to pay for an annual routine physical exam provided on December 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 12, 2022. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says the member 
received services from a provider who had opted out of the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for an office 
visit provided on December 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on August 11, 2022. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for laboratory services provided on August 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99497 and 99498 billed for date of service 
September 16, 2022. 
 
You asked the Plan to pay for procedure code 99497. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 99497 is bundled into payment for code 99223.  
 
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, we have confirmed that code 99497 
is a column II code to column I code 99223. This claim has not been billed with an appropriate modifier to 
bypass the edit. In addition, we have confirmed that code 99497 is an add-on code and has not been billed with 
an appropriate primary procedure code. Based on the claim submitted, Medicare billing criteria have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 99497 and 99498 billed for 
date of service September 16, 2022.