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

 
We decided that the Plan does not have to pay for an office visit provided on June 28, 2023. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary, you did have a 
referral, however, it was for the wrong 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 an office visit provided 
on June 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for remote patient monitoring services provided on June 15, 
2023, to June 30, 2023. 
 
You asked the Plan to pay for remote patient monitoring 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 remote patient 
monitoring services provided on June 15, 2023, to June 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on April 27, 
2023. 
 
You asked the Plan to pay for the DecisionDx-SCC test. You say that this testing is medically necessary. The 
Plan denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 We looked at the file and Medicare rules. This test is listed in the DEX database as not covered. Based on this 
information, we decided that Medicare rules for coverage of the DecisionDx-SCC test have not been met. 
Therefore, we decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on 
April 27, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the 
Plan's 48-trip limit. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you need transportation to 
medical appointments. The Plan denied your request. The Plan says the requested trips will exceed your 
transportation limit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the Plan's 
48-trip limit.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 07, 2023. 
 
You asked the Plan to pay for an office visit. You say that this visit was 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 an office visit provided 
on March 07, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service provided on January 07, 2023, to 
February 04, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that you are requesting reconsideration of 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 the laboratory service 
provided on January 07, 2023, to February 04, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on April 28, 2023, by an out-of-network 
(OON) provider.  
 
You asked the Plan to pay for lab testing. You say that you are asking to overturn the no authorization denial 
and please review the medical records attached to process this claim. The Plan denied your request. The Plan 
says the enrollee must receive their care from a network provider (for more information about this, see Section 
2 of Chapter 3). In most cases, care the enrollee receives from an out-of-network provider (a provider who is 
not part of the plans network) will not be 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 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 lab testing provided on April 28, 2023, by an out-
of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the TissueCypher Barret's Esophagus testing (0108U) 
provided on February 15, 2023. 
 
You asked the Plan to pay for the TissueCypher Barret's Esophagus testing. You say that this testing was 
medically necessary. The Plan denied your request. The Plan says issueCypher Barrett's Esophagus test 
remains unproven for determining the risk of progression from Barrett's esophagus to high grade dysplasia or 
cancer. 
 
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 TissueCypher Barret's Esophagus 
testing. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that TissueCypher testing is not standard of care and not 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the TissueCypher Barret's Esophagus testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the TissueCypher Barret's Esophagus testing (0108U) provided 
on February 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ECG provided on July 21, 2023, by an OON provider.  
 
You asked the Plan to pay for the ECG. You say that you are requesting reconsideration of the denied claim. 
The Plan denied your request. The Plan says the 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the ECG provided on July 21, 2023, by an OON 
provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound polymerase chain reaction (PCR) testing (87798, 
87801) provided on December 1, 2022. 
 
You asked the Plan to pay for the wound PCR testing. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says experimental or investigation services are excluded from coverage. 
 
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 wound PCR testing. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the longstanding standard of care for the evaluation of bacteria in a wound is the 
performance of a culture and sensitivity. This laboratory test is inexpensive, sensitive, and specific. It is unclear 
as to why this enrollee's wound required PCR testing as compared to a gram stain and culture and sensitivity. 
Therefore, the PCR testing of this enrollee' s right foot wound was not medically reasonable or necessary at this 
time. 
 
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 wound PCR testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the wound polymerase chain reaction (PCR) testing (87798, 87801) provided on 
December 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six pain management visits to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve six pain management visits by an OON provider. You say that you do not 
agree with the denial because you need your pain medication. 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 
six pain management visits to be provided by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve maxillary partial denture (D5225) and mandibular 
partial denture (D5226). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. 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 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 the requested item or service was exhausted on date of service September 1, 2020. 
Therefore, we decided that the Plan does not have to pre-approve maxillary partial denture (D5225) and mandibular partial denture (D5226).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton treatment delivery. 
 
You asked the Plan to pre-approve proton treatment delivery. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 proton treatment delivery. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found proton beam therapy is not medically reasonable and necessary in this case. There is 
insufficient prospective, long-term clinical data available to determine whether or not proton beam radiation 
therapy for prostate cancer is superior, inferior, or equivalent to external beam radiation therapy, intensity-modulated radiation therapy (IMRT), or brachytherapy with regards to safety and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton treatment delivery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve proton treatment delivery.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that the PET scan is medically necessary so the 
enrollee can take the new monoclonal antibodies against amyloid for Alzheimer's disease. The Plan denied 
your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the enrollee is only noted to be suspected 
of having AD and not suspected of having AD and FTD. In as much, the base requirement of the NCD for 
coverage of this service would not be satisfied. 
 
 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an assessment for hearing aid (V5010) and binaural 
hearing aids (V5130). 
 
You asked the Plan to pre-approve an assessment for hearing aid (V5010) and binaural hearing aids (V5130). 
You say that you went to the provider and did an examination for your ears. You also say that they state to wait 
about a week for information about the hearing aids. The Plan denied your request. The Plan says this is not a 
covered benefit under Medicare. 
 
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 you are pregnant or in a nursing facility.  
 
 
  We looked at the filed the Plan's rules. Based on this information, we decided that the Plan's rules for coverage 
of an assessment for hearing aid (V5010) and binaural hearing aids (V5130) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an assessment for hearing aid (V5010) and binaural hearing 
aids (V5130).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical nutrition therapy provided on April 07, 2023, to 
May 08, 2023. 
 
You asked the Plan to pay for the medical nutrition therapy. You say that you are requesting reconsideration of 
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 the medical nutrition 
therapy provided on April 07, 2023, to May 08, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for remote physiologic monitoring treatment management 
services provided on February 28, 2022. 
 
You asked the Plan to pay for remote physiologic monitoring treatment management services. You say that you 
are requesting reconsideration for the denied claim. The Plan denied your request. The Plan says the claim 
submission must be filed to the appropriate Medicare claims processing contractor no later than 12 months 
after the date the services were furnished. 
 
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 remote physiologic monitoring treatment management services was not filed 
until June 27, 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 remote physiologic monitoring 
treatment management services provided on February 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (tens) device 
provided on December 16, 2022. 
 
You asked the Plan to pay for the transcutaneous electrical nerve stimulation (tens) device. You say that you 
are requesting reconsideration of 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 the transcutaneous 
electrical nerve stimulation (tens) device provided on December 16, 2022.