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

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

 
We decided that the Plan does not have to pay for Myocardial perfusion imaging, tomographic (SPECT); 
Technetium tc-99m tetrofosmin and Transthoracic Echocardiography (TTE) provided on June 14, 2023 by an 
out-of-network provider. 
 
You asked the Plan to pay for Myocardial perfusion imaging, tomographic (SPECT); Technetium tc-99m 
tetrofosmin and Transthoracic Echocardiography (TTE) provided by an out-of-network provider. You say that 
you called the provider and they told you that no referral was required for these services. The Plan denied your 
request. The Plan says there is no prior authorization or referral on file for this provider. The imaging services 
received were outside of both the Plans geographic service area and network of providers. Additionally, there 
were no abnormal findings, and your vital signs were unremarkable. There was no clear indication for the 
requested studies. The services were not emergent or urgent. There were in-network providers in the area who could have performed these services. There were no exceptions met that warranted a visit to an out-of-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 services at issue in this appeal. 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 Myocardial perfusion imaging, tomographic (SPECT); 
Technetium tc-99m tetrofosmin and Transthoracic Echocardiography (TTE) provided on June 14, 2023 by an 
out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for outpatient surgery provided on June 09, 
2023. 
 
You asked the Plan to waive the coinsurance for outpatient surgery. You say that you say that the doctor order 
you to stay overnight and this was not by your request. 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 5% 
coinsurance for outpatient hospital services. 
 
You have been asked to pay 5% coinsurance for outpatient surgery. This item/service falls within the outpatient 
hospital services 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. The total you owe is $416.88 ($8,337.60 allowed amount x 5% = $416.88). Therefore, we decided 
that the Plan does not have to waive the coinsurance for outpatient surgery provided on June 09, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion services provided on February 24, 2023, to 
March 27, 2023. 
 
You asked the Plan to pay for home infusion services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for home infusion services 
provided on February 24, 2023, to March 27, 2023.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for non-emergent ambulance transportation services provided on June 27, 
2023. 
 
You asked the Plan to pay for the non-emergent ambulance transportation services. You say that the enrollee 
was transferred from the nursing home to the hospital due to their dementia with violent behaviors. The Plan 
denied your request. The Plan says that non-emergency ambulance transportation is covered when it is the only 
way to safely and adequately transport an enrollee or if other means of transporting the enrollee are unsafe due 
to a medical condition. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 non-emergent ambulance transportation 
services. Our reviewer says that the non-emergent transportation services were medically necessary. Our 
physician reviewer found the documentation supports that no other methods of transport would be safe to 
transfer the enrollee from residing facility to psychiatric facility. Transport via non-emergency ambulance was 
medically reasonable and 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 non-emergent ambulance transportation services have been met. Therefore, 
we decided that the Plan has to pay for non-emergent ambulance transportation services provided on June 27, 
2023.  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy visits to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve physical therapy visits. You say that the out-of-network (OON) provider is 
closer in distance to your home. The Plan denied your request. The Plan says the services 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 visits 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 the implant supported crowns (D6065 x 2) and custom 
fabricated abutments (D6057 x 2) provided on July 5, 2023. 
 
You asked the Plan to pay for the dental services. You say that the provider recommended these procedures for 
optimal oral health. The Plan denied your request. The Plan says these services are not covered benefits under 
your dental plan. 
 
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 the 
implant supported crowns (D6065 x 2) and custom fabricated abutments (D6057 x 2) provided on July 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing (87481, 87653, 87798, and 87801) provided 
on July 11, 2023. 
 
You asked the Plan to pay for procedure codes 87481, 87653, 87798, and 87801. You say that you would like 
the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 87481, 87653, 87798, and 87801 are not supported in the medical record. Specifically, 
a panel was performed and there is a more appropriate singular code for the services. Based on this 
information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we 
decided that the Plan does not have to pay for the panel testing (87481, 87653, 87798, and 87801) provided on 
July 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve osseous surgery (D4260, D4261). 
 
You asked the Plan to pre-approve the dental services. You say that these procedures are very expensive but are 
needed for your overall health. The Plan denied your request. The Plan says these services are not covered 
benefits under your dental plan. 
 
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 
osseous surgery (D4260, D4261).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary complete denture (D5110). 
 
You asked the Plan to pre-approve the dental services. You say that your denture never fit properly, and your 
provider said they do not do adjustments. 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 27, 2022. 
Therefore, we decided that the Plan does not have to pre-approve a maxillary complete denture (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial upper denture (D5213). 
 
You asked the Plan to pre-approve the dental service. You say that you do not have any false teeth in your 
mouth. 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 the Plan paid for a partial upper denture (D5213) on April 14, 2021; therefore, your benefit for the 
requested item or service was exhausted on the date of service of April 14, 2021. Therefore, we decided that 
the Plan does not have to pre-approve a partial upper denture (D5213).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the stereoscopic radiological (x-ray) guidance (G6002), 
radiation treatment (77427), Intensity modulated treatment delivery (G6015), and consultation provided on 
March 28, 2022. 
 
You asked the Plan to pay for the stereoscopic radiological (x-ray) guidance (G6002), radiation treatment 
(77427), Intensity modulated treatment delivery (G6015), and consultation. You say that the services were medically necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the stereoscopic 
radiological (x-ray) guidance (G6002), radiation treatment (77427), Intensity modulated treatment delivery 
(G6015), and consultation provided on March 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extra heavy-duty hospital bed (E0302) and foam 
rubber mattress (E0272). 
 
You asked the Plan to pre-approve an extra. You say that you need this item. The Plan denied your request. The 
Plan says there is no indication you meet the weight requirement for this bed. 
 
The Plan must follow Medicare rules. The rules say that an extra heavy-duty hospital bed (E0302, E0304) is 
covered if the beneficiary meets one of the criteria for a hospital bed and the beneficiary's weight exceeds 600 pounds. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an extra have not been met. Therefore, we decided that the Plan does not have to pre-approve an 
extra heavy-duty hospital bed (E0302) and foam rubber mattress (E0272).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 83520 and 87798 for date of service January 
20, 2023. 
 
You asked the Plan to pay for procedure codes 83520 and 87798. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services billed are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 83520 and 87798 are not supported in the medical record. Specifically, the 
documentation submitted did not include documentation of a complete description of the not otherwise 
specified code; therefore, the billed codes cannot be verified. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 83520 and 87798 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 83520 and 87798 for date of service January 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator system. 
 
You asked the Plan to pre-approve a home ventilator system. You say that the enrollee needs the ventilator to 
breath.  The Plan denied your request. The Plan says a home ventilator is not medically necessary for this 
patient because their needs can be met with an alternative device such as a BiPAP device with average volume-
assured pressure support (AVAPS).   
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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator system. Our reviewer 
says that a home ventilator system is not medically necessary. Our physician reviewer found that there is no 
documentation of chronic carbon dioxide retention. Also, there is no diagnosis of thoracic restrictive disease or 
neuromuscular disease. Therefore, the enrollee does not meet Medicare criteria for either a ventilator or a 
respiratory assist device. 
 
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 home ventilator system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home ventilator system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0651) and 
accessories (E0667) to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a pneumatic compression device and accessories. You say that the service 
should be covered. The Plan denied your request. The Plan says your records received do not indicate that you 
have an emergent or urgent medical condition, or are in need of specialized service(s) that are not available in 
the 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 
a pneumatic compression device (E0651) and accessories (E0667) to be provided by an out-of-network (OON) 
provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
May 12, 2023. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says the PCR testing is considered unproven and not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the urine PCR panel. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the molecular PCR test was not medically reasonable or necessary. Urinalysis with culture 
is an adequate test. 
 
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 urine PCR panel have not been met. Therefore, we decided that the Plan 
does not have to pay for the urine polymerase chain reaction (PCR) panel provided on May 12, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wireless capsule endoscopy (91110). 
 
You asked the Plan to pre-approve a wireless capsule endoscopy. You say that this is medically necessary. The 
Plan denied your request. The Plan says records do not show the enrollee has had a colonoscopy within the last 
12 months that failed to show a cause of bleeding. 
 
The Plan must follow Medicare rules. Medicare rules say that use of wireless capsule endoscopy is indicated 
only if EGD and colonoscopy has been done within the past 12 months and failed to identify a bleeding source. 
 
We looked at the file and Medicare rules. Specifically, the medical records show that the enrollee has not had a 
colonoscopy within the past 12 months. Based on this information, we decided that Medicare rules for 
coverage of a wireless capsule endoscopy have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a wireless capsule endoscopy (91110).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient services to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve outpatient services with an out-of-network provider. You say that you want 
to see the requested provider. The Plan denied your request. The Plan says the provider is out-of-network. The 
services are 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 
outpatient services 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 pre-approve a complete upper denture (D5110) and a complete lower 
denture (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that you need the dentures replaced. 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 April 29, 2022. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a 
complete lower denture (D5120).