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

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 the PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the enrollee is not noted to have AD or 
FTD. The cerebrospinal fluid (CSF) testing was said to be inconsistent with AD. There was no indication that 
the member met diagnostic criteria for FTD. This request would not satisfy the base requirement of the NCD 
for coverage of this service. Therefore, this service cannot be said to be reasonable and necessary for the 
enrollee. 
 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the requested  
out-of-network provider beyond the number of visits that the Plan has approved. 
 
You asked the Plan to pre-approve physician's services to be provided by the requested out-of-network 
provider. You say that you are an established patient with this provider. The Plan denied your request. The Plan 
says you must receive care from a 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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by the requested out-of-network provider beyond the number of visits that 
the Plan has approved.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral x-ray (D0210) provided on February 24, 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 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 March 17, 2021. 
Therefore, we decided that the Plan does not have to pay for an intraoral x-ray (D0210) provided on February 
24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the extractions (D7210) for tooth #2 and #14 and to 
pay for the extractions (D7210) for tooth #3, #15, #19, and #30, the deep sedation (D9222 and D9223), and the 
therapeutic drugs (D9612) provided by an out-of-network provider on October 24, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you did not know that the provider did not 
accept Medicare and you never received payment from the Plan. 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. Also, the denial of payment for the deep sedation and the 
therapeutic drugs is correct because they are not covered by the 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.  
 
The total billed amount for the extraction (D7210) for tooth #2 was $401 and the total allowed amount was 
$126 leaving a difference of $275 ($401 billed - $126 allowed). The total coinsurance amount was $69.30 
($126 allowed x 55% coinsurance). The total billed amount for the extraction (D7210) for tooth #14 was $401 
and the total allowed amount was $126 leaving a difference of $275 ($401 billed - $126 allowed). The total 
coinsurance amount was $69.30 ($126 allowed x 55% coinsurance). 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment and the coinsurance amount for the extractions. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. The record shows the Plan paid for 2 extractions on October 24, 
2022; therefore, your benefit for the extractions was exhausted on the date of service of October 24, 2022. The 
deep sedation and the therapeutic drugs are not covered under the Plans dental benefits. Therefore, we decided 
that the Plan does not have to pay more for the extractions (D7210) for tooth #2 and #14 and to pay for the 
extractions (D7210) for tooth #3, #15, #19, and #30, the deep sedation (D9222 and D9223), and the therapeutic 
drugs (D9612) provided by an out-of-network provider on October 24, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided from June 27, 2022, through June 30, 
2022, and July 21, 2022, through July 26, 2022. 
 
You asked the Plan to pay for SNF care. The Plan denied your request. The Plan says the enrollee no longer 
had skilled nursing facility needs.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee did not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for SNF care provided from June 27, 2022, through June 30, 2022, and July 21, 2022, through July 26, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued use of a home ventilator (E0466). 
 
You asked the Plan to pre-approve continued use of a home ventilator. You say that you are requesting 
reconsideration due to medical necessity. The Plan denied your request. The Plan says the records do not show 
that the request for a non-invasive ventilator (NIV) to be used exclusively in AVAPS mode is medically 
necessary since there is no current clinical documentation that BiPAP has been found to be ineffective for the 
enrollee. There are BiPAP machines available that have AVAPS functionality if it becomes necessary in the 
future. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve continued use of a home ventilator. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee has COPD, 
severe obesity with obesity hypoventilation syndrome, and HFpEF. The FEV1 was reported as 56% of 
predicted in December 2021, with an obstructive pattern, although the report is not provided. The enrollee was 
provided with a ventilator in the AVAPS-AE mode following a hospitalization in January 2021. Device 
download covering April 12, 2023, to May 11, 2023, shows use of the device for at least 4 hours/day for 70% 
of days. It appears this enrollee's ventilatory needs could be met with BiPAP with AVAPS-AE. Medicare does 
not cover a home ventilator when used at settings that can be provided with BiPAP. The plan has approved the 
ventilator for 3 months, which provides time for transition to BiPAP.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued use of a home ventilator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve continued use of a home ventilator (E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5140) purchased on 
February 13, 2023. 
 
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.  
 
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. The Plan pays for 
hearing aids only when purchased from the Plans select hearing aid provider.  
 
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 states that hearing aids are covered 
only when purchased from the Plans select hearing aid provider. However, the hearing aids in this case were 
purchased from an out-of-network provider. Therefore, we decided that the Plan does not have to issue 
reimbursement for the hearing aids (V5140) purchased on February 13, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on January 5, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you fell 
and were not able to get up so emergency medical services were called.  The Plan denied your request. The 
Plan says these services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on January 5, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on January 5, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit and nail debridement provided on April 03, 2023. 
 
You asked the Plan to pay for home visit and nail debridement. You say that you are appealing the claim 
payment denial. 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 visit and nail 
debridement provided on April 03, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve porcelain/ceramic pontics for teeth number 9 and 10 
(D6245 x 2). 
 
You asked the Plan to pre-approve the dental items. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says your benefit for the requested items 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 items has been exhausted. Specifically, the Plans contract states that up to 
four units of fixed dentures are covered per year. The Plan previously authorized four units of fixed dentures 
for teeth number 6, 7, 8, and 11. Therefore, you have exhausted the allowable benefit for the requested dental 
items in this case. Therefore, we decided that the Plan does not have to pre-approve porcelain/ceramic pontics 
for teeth number 9 and 10 (D6245 x 2).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would benefit from and 
improve with LTACH care. The Plan denied your request. The Plan says the LTACH services requested do not 
meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving acute hospital care, and acute care services have not been 
denied. The documentation shows there are no required medical services identified that are available at the 
LTACH, that are not available at the current health care setting being offered by the health plan. 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on October 20, 2022. 
 
You asked the Plan to pay for lab testing. You say that you are requesting the submitted documentation be 
reviewed. 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 lab testing provided on 
October 20, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compounded drugs (J3490-KD) provided on October 6, 
2022. 
 You asked the Plan to pay for the compounded drugs with code J3490-KD. 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 as billed. 
 
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 looked at the file and the rules. The rules require that any compounded drug be billed using the not 
otherwise classified code J7999. As these compounded drugs were not billed properly, payment cannot be 
made. Therefore, we decided that the Plan does not have to pay for the compounded drugs (J3490-KD) 
provided on October 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional moderate sedation time provided on date of 
service February 8, 2023, billed with code 99153. 
 
You asked the Plan to pay for procedure code 99153. You say that this should be paid for. The Plan denied 
your request. The Plan says code 99153 is not payable in the facility setting.  
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.   
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does 
not have to pay for the additional moderate sedation time provided on date of service February 8, 2023, billed 
with code 99153.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hearing aids to be rendered by an out-of-network 
(OON) provider.   
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says there are in-network providers available to render the 
requested items.  
 
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. The Plan pays for 
hearing aids only when purchased from the Plans select hearing aid provider.  
 
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 states that hearing aids are only 
covered when purchased from the Plans select hearing aid provider. However, your request in this case is for 
hearing aids from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-
approve hearing aids to be rendered by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for diabetic supplies provided on January 16, 
2023, and February 16, 2023. 
 
You asked the Plan to waive the cost share for diabetic supplies. You say that you have never been charged a 
cost share amount before, so you do not think you should have to pay the billed amount. 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 non-OneTouch/LifeScan supplies, including test strips, glucose monitors, solutions, lancets, 
and lancing devices, with a medical exception. 
 You have been asked to pay a total of $130.31 for diabetic supplies.  
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
January 16, 2023 Diabetic supplies $536.78 20% $107.36 
February 16, 2023 Diabetic supplies $114.75 20% $22.95 
TOTAL:    $130.31 
 
The diabetic supplies fall within the diabetic self-management training, diabetic services, and 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 cost share for diabetic supplies provided on January 16, 2023, 
and February 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implants (D6010 x10). 
 
You asked the Plan to pre-approve the dental services. You say that you are requesting an expedited 
reconsideration for the denial of the requested implants. The Plan denied your request. The Plan says the 
benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the benefit for the requested item or service was exhausted on July 3, 2023 when the Plan authorized 
implants for tooth #3 and tooth #5. Therefore, we decided that the Plan does not have to pre-approve surgical 
placement of implants (D6010 x10).