Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgery provided on December 08, 2022. 
 
You asked the Plan to pay for surgery. You say that you are requesting reconsideration for the services 
provided. 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 surgery provided on 
December 08, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the specialist office visit provided on 
March 22, 2023. 
 
You asked the Plan to reduce the copayment for the specialist office visit. You say that you should not have to 
pay for an office visit. 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 $15 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $15 copayment for the specialist office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to reduce the copayment for the specialist office visit provided on March 22, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for x-rays on December 29, 2022.  
 
You asked the Plan to waive the copayment for x-rays. You say that you should not have to pay the copayment 
because the x-rays couldn't be used. 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 $100 
copayment when X-rays are performed in an outpatient hospital facility. Covered services include but are not 
limited to X-rays. The provider billed in the amount of $387 and the allowed amount is $75.76 for the service. 
This is less than the copayment amount. Therefore, results in the total cost sharing amount of $75.76. 
 
 You have been asked to pay a $75.76 copayment, which is less than the copayment for x-rays. This 
item/service falls within the outpatient diagnostic tests and therapeutic services and supplies 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 x-rays on December 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a preventive medicine reevaluation provided on March 20, 
2023, by an OON provider.  
 
You asked the Plan to pay for a preventive medicine reevaluation. You say that you are requesting 
reconsideration of the denied claim. The Plan denied your request. The Plan says this service was not 
authorized. 
 
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 Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 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 preventive medicine reevaluation provided on 
March 20, 2023, by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Leqembi (J0174). 
 
You asked the Plan to pre-approve Leqembi. You say that Leqembi is a medical necessity for the enrollee. The 
Plan denied your request. The Plan says Leqembi has been prescribed for an off-label, not medically accepted 
use. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Leqembi. Our reviewer says that 
treatment with Leqembi is not medically reasonable and necessary in this case. Our physician reviewer found 
that the requested use of Leqembi is FDA-approved for the enrollee's diagnosis; however, the major drug 
compendia state that "Testing for ApoE e4 status should be performed prior to initiation of treatment [with 
Leqembi] to inform the risk of developing ARIA [amyloid-related imaging abnormalities]." No record of ApoE e4 testing or discussion of ARIA is documented in this case. The use of Leqembi without ApoE e4 testing or 
discussion of ARIA is not supported by one of the major drug compendia or by clinical research that appears in 
a Medicare-approved medical journal. The use of Leqembi without ApoE e4 testing or discussion of ARIA 
does not meet Medicare criteria for safety and effectiveness. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Leqembi have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Leqembi (J0174).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve OneTouch Verio Test Strips. 
 
You asked the Plan to pre-approve OneTouch Verio Test Strips. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says the services are available from the Plan's 
preferred providers. 
 The Plan must follow Medicare rules. The rules say that Plans may limit enrollees to preferred providers for 
durable medical equipment and supplies. 
 
We looked at the file and Medicare rules. The requested services are OneTouch Verio Test Strips. OneTouch is 
not a preferred provider with the Plan. Test strips are available from the Plan's preferred providers that the 
enrollee has not tried. Therefore, we decided that the Plan does not have to pre-approve OneTouch Verio Test 
Strips.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on March 22, 2023. 
 
You asked the Plan to pay for lab testing. You say that you are requesting the submitted documentation be 
reviewed. 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 lab testing provided on 
March 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit, and psychotherapy services provided on 
February 9, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the office visit, and the psychotherapy services. You say that the provider is in-
network. 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 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 
items/services 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 office visit, and psychotherapy services 
provided on February 9, 2023, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the abdomen. 
 
You asked the Plan to pre-approve the MRI. You say that the services are medically necessary. The Plan 
denied your request. The Plan says that they need results of the prior approved study that show the need for 
repeat imaging, or your doctor must confirm that the prior approved study was not performed. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the 
service is medically necessary. Our physician reviewer found a periodic MRI based on the risk of recurrence is 
a standard of care for the surveillance of soft tissue sarcoma of the extremities. This is based on the national 
comprehensive cancer network (NCCN) guidelines Version 2.2023 Soft Tissue Sarcoma. The service is 
reasonable and medically necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the MRI have been met. Therefore, we decided that the Plan has to pre-approve 
a magnetic resonance imaging (MRI) of the abdomen.  
 
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 implant retainer crowns (D6068), and pontics (D6245). 
 
You asked the Plan to pre-approve D6068 and D6245. You say that these procedures are not cosmetic. The 
Plan denied your request. The Plan says these services havebeen correctly denied. 
 
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 
implant retainer crowns (D6068), and pontics (D6245).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an OON provider.  
 
You asked the Plan to pre-approve physical therapy. You say that there are no in-network physical therapy 
providers near you. The Plan denied your request. The Plan says the service can be provided by an in-network 
provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
physical therapy to be provided by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interim crown (D2799) for tooth #15. 
 
You asked the Plan to pre-approve D2799. You say that you need this dental work done. The Plan denied your 
request. The Plan says the denied service is not a covered benefit. 
 
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 
interim crown (D2799) for tooth #15.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the core build-up (D2950) on tooth #5 and the crown 
(D2740) on tooth #5. 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee presented for root canal 
therapy (RCT), but the RCT cannot be done, and you are recommending a new crown. The Plan denied your 
request. The Plan says your benefits for the requested services have already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for D2950 and D2740 was exhausted when the Plan pre-approved these services on June 19, 2023. Therefore, we decided that the Plan does not have to pre-approve the core build-up (D2950) on tooth 
#5 and the crown (D2740) on tooth #5.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the use of a special device to increase the space between 
vertebra (Vertiflex) procedure. 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that the enrollee has suffered from his 
condition for over 15 years which has affected his quality of life. The appellant says they recommend this 
minimally invasive procedure when conservative treatment has failed and is a safer alternative to a 
laminectomy or spinal fusion procedure. The Plan denied your request. The Plan says the Vertiflex procedure is 
not medically necessary. The Plan says unproven and medically necessary procedures are not covered by 
Medicare due to insufficient evidence of efficacy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Vertiflex procedure. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the Vertiflex device is experimental. 
 
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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the use of a special device to increase the space between vertebra (Vertiflex) 
procedure.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance services billed with codes A0428 x2 and A0425 x2 for date 
of service June 2, 2022. 
 
You asked the Plan to pay for the codes A0428 x2 and A0425 x2. You say that the submitted records support 
the medical necessity for the ambulance transport. The Plan denied your request. The Plan says that this 
procedure exceeds the maximum number of services allowed under our guidelines for a single date of service. 
 
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 has not provided clear information regarding which trips 
remain paid and the cited limitation on trips in one day is not a Medicare rule. The Plan has not substantiated 
their denial reason. Therefore, we decided that the Plan has to pay for ambulance services billed with codes 
A0428 x2 and A0425 x2 for date of service June 2, 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 wound care supplies provided on February 15, 2023. 
 
You asked the Plan to pay for wound care supplies. You say that this item does not need an authorization, and 
can be billed separately from the skilled nursing facility. 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 wound care supplies 
provided on February 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an annual wellness visit provided on October 17, 2022. 
 
You asked the Plan to pay for an annual wellness visit. You say that this is supported in the records. 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 annual wellness visit 
provided on October 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a custom fabricated abutment (D6057) and an implant 
supported porcelain/ceramic crown (D6065) provided on March 9, 2023. 
 
You asked the Plan to pay for the dental services. You say that the Plan representative assured you that your 
procedure covered at 100%. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted.  

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 9, 2023, with this 
service. The record shows you are responsible for $1,937 for the amount over your annual $1,000 maximum. 
Therefore, we decided that the Plan does not have to pay for a custom fabricated abutment (D6057) and an 
implant supported porcelain/ceramic crown (D6065) provided on March 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve an office visit. You say that you do not want to start with someone that does 
not know your health history. The Plan denied your request. The Plan says there are providers in-network who 
can 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 
an office visit 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 wound care provided on February 20, 2023. 
 
You asked the Plan to pay for wound care. You say that you say that wound care supplies are a separately 
billable expense that does not require authorization or referral. 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 wound care provided on 
February 20, 2023.