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

 
We decided that the Plan does not have to pay for the diabetic testing supplies provided on June 26, 2023. 
 
You asked the Plan to pay for the diabetic testing supplies. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. Review of the file shows that the documentation did not include an order for a continuous glucose monitor. The record shows that the Plan made several attempts to obtain the necessary documentation without 
success. Therefore, we decided that the Plan does not have to pay for the diabetic testing supplies provided on 
June 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99348 provided on August 2, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for procedure code 99348. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent 
nor urgent and prior authorization was not obtained to provide OON care. 
 
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 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 procedure code 99348 provided on August 2, 
2023, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous ablation therapy (36475). 
 
You asked the Plan to pre-approve the endovenous ablation therapy. You say that the patient requires bilateral 
radiofrequency ablation. The Plan denied your request. The Plan says the records do not show appropriate 
failure of conservative therapy. 
 
The Plan must follow Medicare rules. Medicare rules say that the treatments of the tributary veins will be 
considered medically necessary if the patient remains symptomatic after a six-week trial of conservative 
therapy. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the endovenous ablation therapy have not been met. Specifically, there are no records to indicate 
that the patient has completed six-weeks of conservative therapy. Therefore, we decided that the Plan does not 
have to pre-approve endovenous ablation therapy (36475).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 10, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services rendered are not covered when provided by an OON 
provider. 
 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the 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 the laboratory services provided on August 10, 
2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit received on September 19, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for the office visit. You say that the Plan does not have a provider who practices 
opioid use disorder treatment services. The Plan denied your request. The Plan says the services received are 
not covered when received by an OON provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the 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 the office visit received on September 19, 2023, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment provided on 
September 27, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the chiropractic manipulative treatment. The Plan denied your request. The Plan 
says that the chiropractic manipulative treatment is available in network. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 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 the chiropractic manipulative treatment provided 
on September 27, 2023, by an out-of-network (OON) provider.
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 out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve an office visit. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says this provider is out-of-network and the services 
could be performed in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the crown - porcelain/ceramic (D2740), and core 
buildup, including any pins when required (D2950) provided on June 19, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you contacted the plan and the provider to 
obtain the missing/requested information for the services rendered on June 19, 2023. The Plan denied your 
request. The Plan says your benefit for the requested services 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 services was exhausted on date of service May 24, 2023, and on the 
appealed claim. The Plan has provided evidence of having made payments totaling $2,000 towards the cost of 
dental services provided in 2023. This included a partial payment of $1,821 towards the crown and core 
buildup. Therefore, we decided that the Plan does not have to pay more for the crown - porcelain/ceramic 
(D2740), and core buildup, including any pins when required (D2950) provided on June 19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant Reveal testing (81479) provided on September 30, 
2023. 
 
You asked the Plan to pay for Guardant Reveal. You say that this test was necessary and is supported in the 
medical record. The Plan denied your request. The Plan says this test is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. Once this is complete, the test is assigned a 
reimbursement rate and a unique test identifier. 
 We looked at the file and Medicare rules. This test is listed in the DEX database as non-covered. This 
determination was made and is specific to the test at issue. Based on this information, we decided that 
Medicare rules for coverage of Guardant Reveal have not been met. Therefore, we decided that the Plan does 
not have to pay for Guardant Reveal testing (81479) provided on September 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel rendered on 
September 27, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that a test panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. The file shows that the test panel was not billed as a single unit of 
service. Based on this information, we decided that Medicare rules for coverage of these services have not been 
met. Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) 
panel rendered on September 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the contact lenses provided on July 7, 2023. 
 
You asked the Plan to pay for the contact lenses. You say that the contact lenses were medically necessary, and 
you only received about 40% of what you paid and are requesting the remaining amount. The Plan denied your 
request. The Plan says the benefit has been exhausted. 
 
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 a $100 allowance for supplemental eyewear every year. 
 
We looked at the file and the Plan's rules. Specifically, the Plan paid $100 on January 20, 2023, which 
exhausted the benefit. Based on this information, we decided that the Plan's rules for coverage of the contact 
lenses have not been met. Therefore, we decided that the Plan does not have to pay for the contact lenses 
provided on July 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for immunization services provided on August 18, 2023. 
 
You asked the Plan to pay for immunization services. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says the requested services are non-covered. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide immunization 
services. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to immunization 
services. Therefore, we decided that the Plan does not have to pay for immunization services provided on 
August 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adjunctive pre-diagnostic test that aids in detection of 
mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy 
procedures (D0431) provided on September 18, 2023. 
 
You asked the Plan to pay for the adjunctive pre-diagnostic test. You say that the provider is in-network. You 
also say that you would like to have your bill for dental work resubmitted and covered as it always has been in 
the past with this provider. The Plan denied your request. The Plan says this service is not covered. 
 
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 service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the adjunctive 
pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant 
lesions, not to include cytology or biopsy procedures (D0431) provided on September 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 96040 billed for date of service September 
14, 2023. 
 
You asked the Plan to pay for procedure code 96040. You say that no other provider saw this patient on this 
date of service. You also say that the medical records support the medical necessity of this service. The Plan 
denied your request. The Plan says procedure code 96040 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 96040 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 96040 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 96040 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 96040 billed for date of service September 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial nursing facility care (99305) and comprehensive 
assessment of and care planning for patients requiring chronic care management services (G0506) provided on 
August 2, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the evaluation and management services. You say that the enrollee did not have a 
choice of what provider they were able to see. You also say that it is not possible to request authorization 
before services are rendered. The Plan denied your request. The Plan says prior authorization was not obtained. 
 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 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 item/service 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 initial nursing facility care (99305) and comprehensive assessment of and 
care planning for patients requiring chronic care management services (G0506) provided on August 2, 2023, by 
an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM), supplies and 
accessories provided on June 30, 2023. 
 
You asked the Plan to pay for the CGM, supplies and accessories. You say that you have submitted proof of 
delivery along with other supporting documentation, but the claim keeps denying for missing this information. 
The Plan denied your request. The Plan says the provider is not a plan contract provider and is not enrolled in 
Medicare as a durable medical equipment supplier. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
 Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor (CGM), 
supplies and accessories provided on June 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) billed with code 
E0676 for January 23, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a pneumatic compression device (PCD) that provides 
intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is not 
covered.  
 
We looked at the file and Medicare rules. The services at issue are a PCD coded E0676. These services are not 
covered by Medicare. Therefore, we decided that the Plan does not have to pay for the pneumatic compression 
device (PCD) billed with code E0676 for January 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the alcohol treatment plan services identified with code 
T1007 billed for date of service January 3, 2023. 
 
You asked the Plan to pay for the alcohol treatment plan services identified with code T1007. You say that you 
feel these services should be covered. The Plan denied your request. The Plan says the services received are not 
a covered benefit. 
 
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 T1007 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code T1007 is not valid for Medicare purposes. In addition, the documentation shows that you were 
advised these services were non-covered prior to receiving them. Based on this information, we decided that Medicare rules for coverage of the alcohol treatment plan services identified with code T1007 have not been 
met. Therefore, we decided that the Plan does not have to pay for the alcohol treatment plan services identified 
with code T1007 billed for date of service January 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve InTandem device. 
 
You asked the Plan to pre-approve InTandem device. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested device is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve InTandem device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has a diagnosis of cerebellar stroke syndrome. As stated by the device 
manufacturer, the InTandem device is "for at-home use to improve walking and ambulation in adults living 
with chronic stroke walking impairments. InTandem is an evidence-based neurorehabilitation system based on 
the principles of Rhythmic Auditory Stimulation (RAS)." The enrollee does have a history of stroke (which is a condition for which the device is indicated), but records do not adequately clarify the enrollees ambulatory 
dysfunction to show necessity of the InTandem device. Medical records report the enrollee "Engages in regular 
physical activity, including walking two miles a day, jump rope, and jumping jacks". The provided medical 
records and review of the current peer-reviewed medical literature do not document that use of the InTandem 
device has been shown in controlled studies in a Centers for Medicare & Medicaid Services-approved journal 
to result in sustained long term health benefits in the Medicare population with cerebellar stroke syndrome. As 
summarized in the Guidelines for adult stroke rehabilitation and recovery: "Rhythmic auditory cueing is a 
therapy approach in which overground walking is synchronized to a rhythmic auditory cue to improve temporal 
and spatial gait measures. An evidence synthesis found moderate evidence of improved velocity and stride 
length in people with stroke after gait training with rhythmic music. Synchronizing walking to rhythmic 
auditory cues can result in short-term improvement in gait measures of people with stroke. Further high-quality 
studies are needed before recommendations for clinical practice can be made. Therefore, the enrollee does not 
meet criteria for the requested device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of InTandem device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve InTandem device.