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

 
We decided that the Plan does not have to pay for an office visit provided on January 11, 2023, by an  
out-of-network provider. 
 
You asked the Plan to pay for the office visit. You say that  The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent 
or emergent, nor were they 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 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 an office visit provided on January 11, 2023, by an  
out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (81404, 81234, 81187, 81406). 
 
You asked the Plan to pre-approve genetic testing. You say that this service is medically necessary. The Plan 
denied your request. The Plan says this test is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that MolDX will only cover and reimburse tests that 
demonstrate analytical and clinical validity, and clinical utility at a level that meets the Medicare reasonable 
and necessary requirement. 
 
We looked at the file and Medicare rules. The requested tests- Myotonia Panel and XomeDX- are not approved 
tests. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been 
met. Therefore, we decided that the Plan does not have to pre-approve genetic testing (81404, 81234, 81187, 
81406).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the retainer crowns-porcelain fused to high noble metal 
(D6750 x 2) and the pontics-cast high noble metal (D6210 x 2) provided on January 9, 2023. 
 
You asked the Plan to pay for these dental items. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the items provided in this case are not payable 
as associated procedures were performed prior to your enrollment in dental coverage. 
 
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 items provided in this case do not 
meet criteria for coverage under this benefit. Specifically, there is no coverage for items/services related to 
multi-visit procedures such as endodontics, crowns, bridges, inlays, onlays, and dentures that are started prior 
to the date dental coverage began. In this case, dental services associated with these dental items were 
performed prior to your enrollment in dental coverage on January 1, 2023. Therefore, we decided that the Plan 
does not have to pay for the retainer crowns-porcelain fused to high noble metal (D6750 x 2) and the pontics-
cast high noble metal (D6210 x 2) provided on January 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services provided on September 20, 
2022. 
 
You asked the Plan to pay for the physical therapy services. You say that you are asking for 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 physical therapy 
services provided on September 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implantation of a disc tissue allograft (Via Disc) 
(0627T). 
 
You asked the Plan to pre-approve the Via Disc NP allograft procedure. You say that the denial for this 
procedure is unwarranted and unsupported by the enrollee's current medical status and is inconsistent with 
currently accepted medical practice. The Plan denied your request. The Plan says a Via disc injection is 
considered an experimental and investigational procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Via Disc NP allograft procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the implantation of a disc tissue allograft (Via Disc) (0627T).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 21, 2022. 
 
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says documentation does not support the service billed. The provider failed to 
submit the requested medical records. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the office visit have been met. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on June 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided from November 5, 2021, to 
November 9, 2021. 
 
You asked the Plan to pay for nursing facility care. You say that the claim was filed timely. The Plan denied 
your request. The Plan says the provider did supply evidence that claim was attempted to be billed once before, 
but provider failed to re-file claim within timely file, despite being timely notified of rejection of initial claim. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for nursing facility care was not filed until January 18, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for nursing facility care provided from November 5, 2021, to 
November 9, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial skilled nursing care provided on October 20, 2022, by 
an OON provider. 
 
You asked the Plan to pay for skilled nursing care. You say that you are asking for reconsideration of the 
denied claim. The Plan denied your request. The Plan says that 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 Plan contract also says that the enrollee POS benefit only 
applies to routine dental services. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for initial skilled nursing care provided on October 
20, 2022, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental 
pneumatic appliances (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliances. You say that you are 
requesting an appeal regarding the denial of coverage for the Flexitouch pneumatic compression pump 
prescribed to treat lymphedema. The Plan denied your request. The Plan says the enrollee does not meet the 
LCD criteria for an advanced lymphedema pump as there is no failed four-week trial of a basic pneumatic 
compression device of either E0650 or E0651. 
 
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) and segmental pneumatic appliances (E0667).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dupixent. 
 
You asked the Plan to pre-approve Dupixent. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug is not a covered benefit. 
 
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 Dupixent.   
Benefits for Dupixent 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a life alert system. 
 
You asked the Plan to pre-approve a life alert system. You say that the enrollee lives alone and faces many 
challenges alone. You feel the enrollee would benefit from this assistance. The Plan denied your request. The 
Plan says this device is considered a convenience item and not primarily medical in nature and is not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a life alert system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued coverage of a home ventilator (E0466) to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve continued coverage of a home ventilator. You say that this device is 
medically necessary. The Plan denied your request. The Plan says the device is not being used as required, and 
the provider is not 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 at issue in this appeal. We found no exception that would require the Plan to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approve continued 
coverage of a home ventilator (E0466) to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve premium blood glucose test strips (A4253). 
 
You asked the Plan to pre-approve premium blood glucose test strips. You say that the items are necessary. The 
Plan denied your request. The Plan says only the preferred brand products listed in the EOC are covered. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for premium blood glucose test strips. Therefore, we decided that the Plan does not have to pre-approve 
premium blood glucose test strips (A4253).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on October 7, 2022. 
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says this provider type is 
not part of the Medicare program. 
 
The Plan must follow Medicare rules. Medicare rules say that a Licensed Professional Counselor is not eligible 
to participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Licensed Professional 
Counselor. Medicare says that a Licensed Professional Counselor is not eligible to participate in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for psychotherapy provided on 
October 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation (code 99152) provided on 
November 1, 2022. 
 
You asked the Plan to pay for moderate sedation. The Plan denied your request. The Plan says there is no 
authorization for this service. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for moderate 
sedation (code 99152) provided on November 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A4465. 
 
You asked the Plan to pre-approve the compression stockings. You say that you are appealing the denial for the 
non-elastic binders because your legs get extremely swollen due to lymphedema. The Plan denied your request. 
The Plan says this item is not covered.  
The Plan must follow Medicare rules. The rules say that compression stockings described by code A4465 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A4465.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre Reader and Sensor. 
 
You asked the Plan to pre-approve the Freestyle Libre Reader and Sensor. The Plan denied your request. The 
Plan says the enrollee does not require insulin three or more times daily. 
 
 
 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the Freestyle Libre Reader and Sensor have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a Freestyle Libre Reader and Sensor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and the dental cleaning 
(D1110) provided on October 27, 2022. 
 
You asked the Plan to pay for these dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says the dental services were received from 
an out-of-network provider and are not covered by your supplemental 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. 
 
 
  
 
The record shows you received the dental services from an out-of-network provider. Though the Plan offers a 
dental benefit in excess of Medicare coverage, dental services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pay for the periodic oral 
evaluation (D0120) and the dental cleaning (D1110) provided on October 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5050 x 2) purchased on 
December 5, 2022. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says these items are not payable as 
they were purchased from an out-of-network provider, without prior authorization. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case.   
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract provides coverage for hearing aids 
purchased from an out-of-network only when prior authorization has been obtained. However, the hearing aids 
in this case were purchased from an out-of-network provider, without prior authorization. Therefore, we 
decided that the Plan does not have to issue reimbursement for the hearing aids (V5050 x 2) purchased on 
December 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fixed partial denture sectioning (D9120). 
 
You asked the Plan to pre-approve the fixed partial denture sectioning. You say that you need this procedure 
because food keeps getting trapped is causing an infection. You also say that you need this procedure and 
would like to have it approved. The Plan denied your request. The Plan says this service is not covered under 
the benefit package. 
 
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 
fixed partial denture sectioning (D9120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of a benign odontogenic cyst or tumor  
(D7450 x 2), guided tissue regeneration-resorbable barrier, per site (D4266 x 2), bone replacement grafts for 
ridge preservation-per site (D7953 x 2), placement of an intra-socket biological dressing to aid in hemostasis or 
clot stabilization, per site (D7922), collection and application of an autologous blood concentrate product 
(D7921), and a comprehensive oral evaluation (D0150) provided on December 6, 2022 and December 13, 
2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request.  The Plan says the services at issue are not a covered benefit. Additionally, the comprehensive oral evaluation 
provided does not meet criteria for coverage as you have previously exhausted this benefit. 
 
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 services provided are not among 
those covered under this benefit. Additionally, the Plans contract states that a comprehensive oral evaluation is 
covered once every three calendar years. You previously received this service on November 3, 2022, which 
was paid for by the Plan. Therefore, you have exhausted the allowable benefit for this service. Therefore, we 
decided that the Plan does not have to pay for the removal of a benign odontogenic cyst or tumor (D7450 x 2), 
guided tissue regeneration-resorbable barrier, per site (D4266 x 2), bone replacement grafts for ridge 
preservation-per site (D7953 x 2), placement of an intra-socket biological dressing to aid in hemostasis or clot 
stabilization, per site (D7922), collection and application of an autologous blood concentrate product (D7921), 
and a comprehensive oral evaluation (D0150) provided on December 6, 2022 and December 13, 2022.