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

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

 
We decided that the Plan does not have to pre-approve a pneumatic compressor, segmental home model with 
calibrated gradient pressure (E0652) and segmental gradient pressure pneumatic appliance, full leg (E0671). 
 
You asked the Plan to pre-approve a pneumatic compressor and full leg segmental gradient pressure pneumatic 
appliance. 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 follows Medicare rules. Medicare rules say that pneumatic compression devices are covered when 
specific criteria are met. 
 
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 pneumatic compressor and full leg 
segmental gradient pressure pneumatic appliance. Our reviewer says that the services are not medically 
necessary. Our physician reviewer found the documentation does not reveal evidence of objective lymphedema 
extending onto the chest, trunk and/or abdomen. The documentation does not reveal objective evidence of a 
four-week trial of conservative therapy demonstrating failed response to treatment with and E0650 or E0651 
with detailed measurements.  
 
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 pneumatic compressor and full leg segmental gradient pressure pneumatic 
appliance have not been met. Therefore, we decided that the Plan does not have to pre-approve a pneumatic 
compressor, segmental home model with calibrated gradient pressure (E0652) and segmental gradient pressure 
pneumatic appliance, full leg (E0671).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laser cataract surgery. 
 
You asked the Plan to pre-approve laser cataract surgery. You say that you need this eye surgery. The Plan 
denied your request. The Plan says laser surgery is not covered. 
 
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 laser cataract surgery. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found laser technology does not qualify as a covered benefit as defined under Medicare guidelines. There is no scientific information or research that shows its long-term effectiveness and 
improvement on outcomes in treating cataract surgery. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of laser cataract surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve laser cataract surgery.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on February 21, 2023. 
 
You asked the Plan to pay for psychotherapy services. You say that this patient is in a facility, and we depend 
upon facility staff to get referrals and prior authorization. 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 psychotherapy services 
provided on February 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel, 51 or greater 
genes (81455) provided January 25, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that the services were medically necessary and 
therefore payable. The Plan denied your request. The Plan says this service does not meet the requirements of 
the Plan benefits and is 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 laboratory service. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this next generation sequencing for genomic testing is not the 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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for the targeted genomic sequence analysis panel, 51 or greater genes (81455) provided 
January 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection provided on April 27, 2023. 
 
You asked the Plan to waive the coinsurance for an injection. You say that you disagree with the copayment 
applied because you have never had a copayment with previous injections. 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 Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for an injection. This item/service falls within the Medicare Part 
B prescription drugs 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 $276.22, which is 20% of the allowed amount for a Medicare Part B drug 
injection ($1,381.08 allowed x 20% = $276.22). Therefore, we decided that the Plan does not have to waive the 
coinsurance for an injection provided on April 27, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a specialist office visit (99214) provided on December 16, 2022. 
 
You asked the Plan to pay for a specialist office visit (99214). You say that the denial of payment says you 
need referral, but per the Plan directory the provider is in-network, and no referral is required. The Plan denied 
your request. The Plan says that seeing an out-of-network provider requires a referral from your primary care 
physician (PCP) or network provider. The Plan also says if you use out-of-network providers without a referral 
or authorization, payment will not be made by the Plan. 
 
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 you see an optometrist, but you must use a provider in the Plan 
Vision Care network. 
 
We looked at the file and the Plan's rules. The Plan rules also say that no referral is required to see an 
optometrist, but you must use a provider in the Plan Vision Care network. The record shows you saw an 
optometrist who was in-network. Based on this information, we decided that the Plan's rules for coverage of a 
specialist office visit (99214) have been met. Therefore, we decided that the Plan has to pay for a specialist 
office visit (99214) provided on December 16, 2022.  
 
  If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for occlusal guards (D9944) provided on April 20, 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 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 occlusal 
guards (D9944) provided on April 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation provided on February 28, 
2023. 
 
You asked the Plan to pay for a psychiatric diagnostic evaluation. You say that the facility is responsible to 
obtain prior authorization. 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 psychiatric diagnostic 
evaluation provided on February 28, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a group 2 heavy-duty power wheelchair (K0825). 
 
You asked the Plan to pre-approve a group 2 heavy-duty power wheelchair. You say that the services are 
necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage 
criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that power mobility devices are covered when specific 
criteria are met. 
 
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 group 2 heavy-duty power 
wheelchair. Our reviewer says that the services are medically necessary. Our physician reviewer found a power 
wheelchair, group 2 heavy-duty, captain's chair, patient weight capacity 301 to 450 pounds is medically 
necessary. The enrollee has a mobility deficit that impairs MRADLs in the home. The mobility deficit is unable 
to be overcome by a manual wheelchair, walker, or cane due to weakness, fall risk, tremors. The enrollee is 
noted to physically and mentally be able to use the requested wheelchair. The July 6, 2022, medical progress 
note indicates the enrollee's current power wheelchair does not support her weight which is 307 lbs. The 
documentation states the enrollee can access all areas of ADLs for cooking, sleeping, eating, toileting. The 
requested wheelchair is 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 a group 2 heavy-duty power wheelchair have been met. Therefore, we decided 
that the Plan has to pre-approve a group 2 heavy-duty power wheelchair (K0825).  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for chemotherapy drugs provided on March 
15, 2023. 
 
You asked the Plan to reduce the coinsurance for chemotherapy drugs. You say that the chemotherapy 
medications were billed double the amount compared to previous times. 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 Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for chemotherapy drugs. This item/service falls within the 
Medicare Part B prescription drugs 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 $4,191.97, which is 20% of the allowed amount for 
Medicare Part B chemotherapy drugs ($20,959.86 allowed x 20% = $4,191.97). Therefore, we decided that the 
Plan does not have to reduce the coinsurance for chemotherapy drugs provided on March 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 1 standard power operated vehicle (K0800). 
 
You asked the Plan to pre-approve a group 1 standard power operated vehicle. 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 follows Medicare rules. Medicare rules say that power mobility devices are covered when specific 
criteria are met. 
 
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 group 1 standard power operated 
vehicle. Our reviewer says that the services are not medically necessary. Our physician reviewer found it is not 
clear the enrollee's condition requires a mobility device. The enrollee has a left hemiparesis but function with a 
cane or walker is not addressed. 
 
 
 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 group 1 standard power operated vehicle have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 1 standard power operated vehicle (K0800).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services billed with multiple codes including 
87541 and 87798 for date of service April 18, 2023. 
 
You asked the Plan to pay for laboratory services. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this panel was not billed in 
accordance with Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components regardless of the fact that the test reports multiple individual pathogens and/or 
targets. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of laboratory services have not been met. Specifically, the service at issue is a test panel which was 
unbundled and billed as individual components. Therefore, we decided that the Plan does not have to pay for 
laboratory services billed with multiple codes including 87541 and 87798 for date of service April 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on February 8, 2023, to February 22, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
approved in advance. 
 
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 the services provided on February 8, 2023, to February 22, 2023, 
by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for dates of service December 8, 
2022, to January 6, 2023. You asked the Plan to pay for the billed services. You say that the NOA was mailed December 9, 2022. The 
Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is December 8, 2022. In this case, there is no documentation to show that the 
NOA was received by the Plan. Based on this information, we decided that the Medicare rules for coverage 
have not been met. Therefore, we decided that the Plan does not have to pay for the home health care billed for 
dates of service December 8, 2022, to January 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup services and gingivectomy (D2950, D4212) 
provided on April 11, 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 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 core 
buildup services and gingivectomy (D2950, D4212) provided on April 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for disposable contact lenses (S0500) provided on May 5, 2023.  
You asked the Plan to pay for disposable contact lenses (S0500). You say that you should have been 
reimbursed $150 according to page 101 of the 2023 EOC. The Plan denied your request. The Plan says the 
maximum benefit was exceeded. 
 
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 $100 toward routine eye wear. 
 
We looked at the file and the Plan's rules. The Plan rules say that there is a $100 plan allowance for routine eye 
wear every year (including eyeglass frames, lenses, and contract lenses). Based on this information, we decided 
that the Plan's rules for coverage of disposable contact lenses (S0500) have not been met. Therefore, we 
decided that the Plan does not have to pay for disposable contact lenses (S0500) provided on May 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service March 18, 
2023. 
 
You asked the Plan to pay for procedure code 99100. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says procedure code 99100 is considered bundled and not 
separately payable.  
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service March 18, 2023.