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

 
We decided that the Plan does not have to pre-approve psychotherapist visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve psychotherapist visit. You say that you believe that kaiser doesn't care about 
your quality of life. The Plan denied your request. The Plan says this is available in-network. 
 
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 
psychotherapist visit to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pontic - indirect resin based composite (D6205) provided on 
December 8, 2022. 
 
You asked the Plan to pay for pontic. You say that this should be covered. The Plan denied your request. The 
Plan says this is not a covered service. 
 
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 pay for pontic - 
indirect resin based composite (D6205) provided on December 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup services (D2950) provided on January 10, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for core 
buildup services (D2950) provided on January 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the aflibercept injection provided on 
August 8, 2022. You asked the Plan to waive the coinsurance for the injection. You say that you disagree with the coinsurance. 
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 20% coinsurance for each Medicare-covered Part B drug.  
 
The enrollee has been asked to pay $390.09, which is 20% coinsurance of the allowed amount for the injection 
($1,950.47 allowed amount x 20% = $390.09). This item/service falls within the Medicare Part B prescription 
drugs benefit category. This means that the enrollee has 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 coinsurance for the aflibercept 
injection provided on August 8, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. The Plan denied your request. The Plan says the requested 
services are not reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer crown on tooth #13 (D6740), the placement of 
an intra-socket biological dressing (D7922), the application of desensitizing medicament on tooth #21 (D9910), 
core build up on tooth #12-14 (D2950), and a pontic on tooth #14 (D6245). You asked the Plan to pre-approve the dental services. You say that you are requesting reconsideration of the 
denied authorization. The Plan denied your request. The Plan says that these services are not covered by your 
dental 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. 
 
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 a 
retainer crown on tooth #13 (D6740), the placement of an intra-socket biological dressing (D7922), the 
application of desensitizing medicament on tooth #21 (D9910), core build up on tooth #12-14 (D2950), and a 
pontic on tooth #14 (D6245).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic apheresis; for plasma pheresis (36514). 
 
You asked the Plan to pre-approve therapeutic apheresis. You say that the enrollee has a form of paraneoplastic 
neurologic disorder, opsoclonus with anti-TA and anti-MA, along with oscillopsia and related ataxia for one 
year and this procedure is medically necessary. The Plan denied your request. The Plan says it is considered not 
medically necessary for the treatment of remote effects of cancer on the nervous system (paraneoplastic 
neurologic syndrome). 
 
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 therapeutic apheresis. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee in this case is believed to have a paraneoplastic syndrome. However, the 
enrollee's diagnosis/condition is not one for which the applicable LCD supports the use of this service. In as 
much, it cannot be said that the Medicare criteria for coverage have been met or that this service would 
otherwise be considered to be medically 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 therapeutic apheresis have not been met. Therefore, we decided that the Plan 
does not have to pre-approve therapeutic apheresis; for plasma pheresis (36514).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the chiropractic services provided from 
December 13, 2022, to December 27, 2022. 
 
You asked the Plan to waive the deductible for the chiropractic services. You say that this provider should be 
considered in-network. 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. Your 
contract with the Plan says that there is a $1,000 deductible which applies to out-of-network chiropractic 
services.  
 
The items or services you asked the Plan to waive the deductible for fall within the chiropractic services benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 
deductible which applies to out-of-network chiropractic services. This cost sharing is a contractual obligation 
that had not been met at the time the chiropractic services were received from December 13, 2022, to 
December 27, 2022. Therefore, we decided that the Plan does not have to waive the deductible for the 
chiropractic services provided from December 13, 2022, to December 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator for 9 months. 
 
You asked the Plan to pre-approve a ventilator for 9 months. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a ventilator for 9 months. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the provided primary source 
documentation does not contain sufficient detailed information in the medical record to justify the treatment 
selected. You could be treated with a bilevel positive airway pressure (BiPAP) machine with intelligent 
volume-assured pressure support (iVAPS) capability and failure of such a device has not been documented. 
The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ventilator for 9 months have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a ventilator for 9 months.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve 5 additional physical therapy visits. 
 
You asked the Plan to pre-approve physical therapy visits. You say that the enrollee would like reconsideration 
because the services are medically necessary. The Plan denied your request. The Plan says that 5 additional 
physical therapy visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 physical therapy visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found that the enrollee is currently having difficulty with hip 
flexion and pain when ambulating. The enrollee requires the assistance of a single point cane and cannot 
actively flex their hip. Due to this being a separate issue from the enrollee's total hip arthroplasty the physical 
therapy would be clinically appropriate. Therefore, the 5 additional physical therapy visits are 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 physical therapy visits have not been met. Therefore, we decided that the Plan 
has to pre-approve 5 additional physical therapy visits.  
   
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 the evaluation and management (EM) services provided on 
January 23, 2022, billed with code 99232. 
 
You asked the Plan to pay for the EM services. You say that this should not have been denied as duplicate. The 
Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly 
denied.  

The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on February 11, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the EM services have not been met. 
Therefore, we decided that the Plan does not have to pay for the evaluation and management (EM) services 
provided on January 23, 2022, billed with code 99232.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 30, 2022, billed with 
codes 81292 and 81321. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says panel testing should be billed using one 
CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
May 30, 2022, billed with codes 81292 and 81321.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an in-network head and neck ultrasound 
provided on February 07, 2023. 
 
You asked the Plan to reduce the copayment for an in-network head and neck ultrasound. You say that you 
were expecting a $40 copayment, not $100. This will cause an extreme hardship for me. 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 for Medicare-covered ultrasound. 
 
You have been asked to pay a $100 copayment for an in-network head and neck ultrasound. This item/service 
falls within the Medicare-covered ultrasound 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 an in-network head and neck ultrasound provided on February 07, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gait training therapy and therapeutic activities provided from 
July 21, 2022, through July 22, 2022.  
You asked the Plan to pay for gait training therapy and therapeutic activities. You say that the claim should be 
reprocessed due to the enrollee being discharged from hospice on July 8, 2022. The Plan denied your request. 
The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on July 8, 2022. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for gait training therapy and 
therapeutic activities provided from July 21, 2022, through July 22, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on December 05, 2022. 
 
You asked the Plan to pay for a nursing facility visit. You say that this was medically necessary and should be 
covered. 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 nursing facility visit 
provided on December 05, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 10, 2023. 
 
You asked the Plan to pay for an office visit. You say that these services are 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 January 10, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on September 9, 2022. 
 You asked the Plan to pay for ambulance services. You say that the enrollee was enrolled in hospice from May 
12, 2022, through September 2, 2022. The Plan denied your request. The Plan says Original Medicare is 
responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on September 2, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for ambulance services 
provided on September 9, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomographic angiography (CTA), abdomen, with contrast material(s) (74175) for the enrollee.
You asked the Plan to pre-approve a CTA of the abdomen. You say that the clinical notes provided support the need for the CTA services in dispute. The Plan denied your request. The Plan says that the provider did not order the correct Current Procedural Terminology (CPT) codes to assess for peripheral arterial disease.
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 a CTA. Our reviewer says that a CTA of the abdomen is not medically reasonable and necessary. This patient has diabetes mellitus and known coronary artery disease. His physical exam revealed present but diminished pulses dorsalis pedis and posterior tibial arteries. He has a smoking history. For all these reasons the possibility of peripheral vascular disease is very likely. The ordered CTA of the abdomen, CPT 74175 is not the correct procedure. Rather the exam to be ordered would be CTA abdominal aorta and iliac arteries with runoff, CPT 75635. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of a CTA of the abdomen.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CTA of the abdomen have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomographic angiography (CTA), abdomen, with contrast material(s) (74175) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periapical first x-ray provided on February 2, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denial. 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 April 19, 2022. 
Therefore, we decided that the Plan does not have to pay for the periapical first x-ray provided on February 2, 
2023.