Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0657). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that this item is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided.  Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652, E0657).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and the knee x-ray provided on July 20, 2023, 
by an OON provider.  
 You asked the Plan to pay for the office visit and x-ray. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says these services are not covered when received by 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 a POS option to use either network providers or out-of-network providers for certain 
covered services. The Plan contract also says that out-of-network outpatient diagnostic tests, including x-rays 
and physician services are not covered. 
 
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 the knee x-ray provided on 
July 20, 2023, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on July 21, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on July 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on August 22, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the office visit. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says this service is not covered when received by 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 a POS option to use either network providers or out-of-network providers for certain 
covered services. The Plan contract also says that out-of-network physician services are not covered. 
 
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 this service. Therefore, we 
decided that the Plan does not have to pay for the office visit provided on August 22, 2023, by an OON 
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Sprint peripheral neurostimulator (PNS) system 
(64555). 
 
You asked the Plan to pre-approve a Sprint PNS system. 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 a Sprint PNS system. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found as the SPRINT PNS device request is not for a trial for a permanently implanted 
device and as the SPRINT PNS electrodes/battery are neither permanent nor surgically implanted, the requested device does not meet criteria for coverage. The review has determined that the SPRINT peripheral 
nerve stimulator, in this case, is not medically reasonable or 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 a Sprint PNS system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Sprint peripheral neurostimulator (PNS) system (64555).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic radiographic imaging (D0330) provided on 
September 30, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. 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 August 31, 2023. 
Therefore, we decided that the Plan does not have to pay for panoramic radiographic imaging (D0330) 
provided on September 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve osseous surgery (D7950), second stage implant service 
(D6104), and a bone graft at time of implant placement (D6011). 
 
You asked the Plan to pre-approve D7950, D6104, and D6011. You say that you constantly have food stuck in 
your teeth, and these implants would help. The Plan denied your request. The Plan says the requested dental 
services are not covered 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 osseous surgery (D7950), second stage implant service (D6104), and a bone graft at time of implant placement 
(D6011).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement foot prosthesis (L5910, L5981, L5986). 
 
You asked the Plan to pre-approve the replacement foot prosthesis. You say that this replacement prosthetic is 
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that payments for repair and maintenance may not 
include payment for parts and labor covered under a manufacturers or suppliers warranty. 
 
We looked at the file and Medicare rules. The enrollee's existing K3 prosthetic foot is covered under 
manufacturer's warranty. The records provided are from the supplier and do not document any reason the 
existing prosthesis is no longer appropriate. Based on this information, we decided that Medicare rules for 
coverage of the replacement foot prosthesis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a replacement foot prosthesis (L5910, L5981, L5986).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (81443, 81329). 
 
You asked the Plan to pre-approve the genetic testing. You say that this service is medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The genetic testing at issue in this appeal is being requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pre-approve 
genetic testing (81443, 81329).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 24, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that this testing 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 the laboratory services 
provided on April 24, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mental health office visit provided on August 2, 2023, by 
an OON provider.  
 
You asked the Plan to pay for the mental health office visit. 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 record shows you are not a network provider with the Plan. The Plan did not pre-approve the item/service 
at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that 
the Plan does not have to pay for the mental health office visit provided on August 2, 2023, by an OON 
provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for individual psychotherapy provided on July 12, 2023. 
 
You asked the Plan to pay for individual psychotherapy. 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 individual 
psychotherapy provided on July 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the transthoracic echocardiogram provided 
on August 16, 2023. 
 
You asked the Plan to waive the coinsurance for the echocardiogram. You say that you should not have been 
charged twice for this test. 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 20% 
coinsurance for outpatient diagnostic tests, including an echocardiogram.  
 
 The record shows this claim was processed correctly and you are responsible for the cost share amount. You 
have been asked to pay $15.74, which is 20% coinsurance of the allowed amount for the professional 
component of the echocardiogram ($78.68 allowed amount x 20% coinsurance = $15.74). You have also been 
asked to pay $112.61, which is 20% coinsurance of the allowed amount for the facility charge for the 
echocardiogram ($563.05 allowed amount x 20% coinsurance = $112.61). This item/service falls within the 
outpatient diagnostic tests and therapeutic 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 
coinsurance for the transthoracic echocardiogram provided on August 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 25, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that this testing 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 the laboratory services 
provided on July 25, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve warfarin sodium. 
 
You asked the Plan to pre-approve the medication. You say that the requested drug is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the medication is not covered as a medical benefit 
under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve warfarin sodium.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging, tomographic (SPECT). 
 
You asked the Plan to pre-approve myocardial perfusion imaging, tomographic (SPECT). You say that the 
requested myocardial perfusion imaging, tomographic (SPECT) is medically necessary. The Plan denied your 
request. The Plan says myocardial perfusion imaging, tomographic (SPECT) does not meet the Medicare 
coverage criteria. 
 
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 myocardial perfusion imaging, 
tomographic (SPECT). Our reviewer says that the requested myocardial perfusion imaging, tomographic 
(SPECT) is not considered medically reasonable and necessary in this case. Our physician reviewer found that 
while the patient has right bundle branch block, there is no documentation that the electrocardiogram (ECG) 
shows an uninterpretable pattern. There is no evidence provided that would support the need for radionuclide 
stress testing. In summary, there is insufficient documentation to support the medical necessity for the 
requested cardiac stress testing in this patients clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of myocardial perfusion imaging, tomographic (SPECT) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve myocardial perfusion imaging, tomographic 
(SPECT).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pontics (D6240), and retainer crowns (D6750) provided on 
August 22, 2023. 
 
You asked the Plan to pay for D6240 and D6750. You say that you need this dental work. The Plan denied your 
request. The Plan says the rendered dental services are not covered 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 pay for pontics 
(D6240), and retainer crowns (D6750) provided on August 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on June 7, 2023. 
 
You asked the Plan to pay for chiropractic services. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says they cover only manual manipulation of the spine to 
correct subluxation. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for chiropractic services provided on June 7, 2023.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for a second emergency department visit (procedure 99285) provided on 
April 9, 2023 
 
You asked the Plan to pay for a second emergency department visit (procedure 99285). You say that the 
enrollee was seen twice on the same date of service at two different times by two different providers. The Plan 
denied your request. The Plan says that the service is a duplicate claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code 99285 is emergency department visit for the evaluation and management of a patient, which requires a 
medically appropriate history and/or examination and high level of medical decision making. 
 
We find that CPT code 99285 is supported in the medical record. Specifically, the two visits were provided by 
separate doctors and for separate problems. One visit was for abdominal pain, and one was for jaw 
pain/difficulty urinating. The appropriate rules for this clinical situation do not specify that a modifier is needed 
in this case. Based on this information, we decided that Medicare rules for coverage of a second emergency 
department visit (procedure 99285) have been met. Therefore, we decided that the Plan has to pay for a second 
emergency department visit (procedure 99285) provided on April 9, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for crown - porcelain/ceramic (D2740) and a core buildup 
(D2950) provided on April 6, 2023, to July 13, 2023. 
 
You asked the Plan to pay more for the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says you are responsible for any charged amount above the Plans cost-sharing amount 
when your services are received from an out-of-network provider. A core buildup 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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. A core buildup is not a covered service. Therefore, we decided that the Plan does not have to pay more for crown - 
porcelain/ceramic (D2740) and a core buildup (D2950) provided on April 6, 2023, to July 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the exam provided on March 2, 2023. 
 
You asked the Plan to pay for the exam . You say that you did not know the facility was out-of-network for 
vision services. The Plan denied your request. The Plan says the services are not covered when received by out-
of-network providers. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when received by a network provider. 
 
We looked at the file and the Plan's rules. Specifically, the provider was out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of the exam have not been met. Therefore, we 
decided that the Plan does not have to pay for the exam provided on March 2, 2023.