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

 
We decided that the Plan does not have to pay for the dermatology office visit and related services provided on 
November 7, 2022, by an OON provider.  
 
You asked the Plan to pay for the dermatology office visit and services. You say that you were told no 
authorization was required. The Plan denied your request. The Plan says these services were 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 has a Point-of-Service (POS) option that lets you use 
doctors and hospitals outside the Plan provider network and prior authorization is required. 
 
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 dermatology office visit and related services 
provided on November 7, 2022, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve maxillary partial denture - flexible base (D5225). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. 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 November 11, 2020. 
Therefore, we decided that the Plan does not have to pre-approve maxillary partial denture - flexible base 
(D5225).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam (D0380) for tooth #29 provided on May 16, 
2023. 
 
You asked the Plan to pay for the dental service. You say that you are appealing the denied dental service. The 
Plan denied your request. The Plan says the denial of payment for this service is correct, because the cone beam 
is 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. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a cone 
beam (D0380) for tooth #29 provided on May 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a segmental pneumatic compression device with 
calibrated gradient pressure chambers (E0652) and appliances (E0671) to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve a segmental pneumatic compression device with calibrated gradient 
pressure chambers and appliances. You say that the items should be covered. The Plan denied your request. 
The Plan says there are in-network providers available to obtain these items from. 
 
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 
a segmental pneumatic compression device with calibrated gradient pressure chambers (E0652) and appliances 
(E0671) 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 for a periodic oral evaluation (D0120) provided on April 17, 
2023. 
 
You asked the Plan to pay for the dental service. You say that the service is required quarterly and it is part of 
your coverage with the Plan. 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 the Plan paid for a periodic oral evaluation (D0120) on January 10, 2023, and paid for a comprehensive 
oral evaluation (D0150) on March 15, 2023; therefore, your benefit for the requested item or service was 
exhausted on the date of service of March 15, 2023. Therefore, we decided that the Plan does not have to pay 
for a periodic oral evaluation (D0120) provided on April 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 2D oral/facial photographic image obtained intra-orally or 
extra-orally (D0350) x2, oral hygiene instructions (D1330) and unspecified periodontal procedure, by report 
(D4999) provided on March 30, 2023. 
 
You asked the Plan to pay for dental services. You say that you do not agree with the denial of payment for 
services you received. The Plan denied your request. The Plan says these services are not covered under your 
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. 2D oral/facial photographic 
image obtained intra-orally or extra-orally (D0350) x2, oral hygiene instructions (D1330) and unspecified 
periodontal procedure, by report (D4999) are not covered under the Plans dental benefits. 
 
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 2D 
oral/facial photographic image obtained intra-orally or extra-orally (D0350) x2, oral hygiene instructions 
(D1330) and unspecified periodontal procedure, by report (D4999) provided on March 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 1 heavy-duty power operated vehicle (POV) 
(K0801). 
 
You asked the Plan to pre-approve a group 1 heavy-duty POV. The Plan denied your request. The Plan says the 
records do not show that you meet the criteria for coverage. The Plan also says that your scooter is described as 
having broken due to excessive wear, and the current scooter is only two years old.  
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 
Medicare rules also state that for equipment to be covered, it must be appropriate and needed for use inside the 
home. 
 
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 heavy-duty POV. Our 
reviewer says that you do not meet the coverage criteria for a replacement power scooter. Our physician 
reviewer found you have 4 out of 5 strength in your upper extremities. The record also indicates that you use 
the scooter outside your domicile, and it is damaged as a result. Our reviewer found that you have subjected the 
POV to excessive use beyond its intended purpose of support for MRADLs in the home. Our physician 
reviewer also found that there is no evaluation indicating you cannot use a manual wheelchair with 4 out of 5 
strength in your arms and legs. 
 
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 heavy-duty POV have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a group 1 heavy-duty power operated vehicle (POV) (K0801).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and garment 
(E0668). 
 
You asked the Plan to pre-approve a pneumatic compression device and garment. You say that the items should 
be covered. The Plan denied your request. The Plan says there is no indication that the enrollee completed the 
Medicare criteria of at least four weeks of daily, multi-hour home usage of a basic lymphedema pump. 
 
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 garment (E0668).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen concentrator (E1390, 99199), purchased on 
December 12, 2022. 
 
You asked the Plan to pay for the oxygen concentrator. You say that this should be covered. The Plan denied 
your request. The Plan says this was purchased through a provider that is not enrolled in Medicare. 
 
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 oxygen concentrator (E1390, 99199), 
purchased on December 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve fitting and placing a post in a tooth (D3950), and a 
surgical procedure for isolation of tooth with rubber dam (D3910). 
 
You asked the Plan to pre-approve fitting and placing a post in a tooth and a surgical procedure for isolation of 
tooth with rubber dam. You say that this should be covered. The Plan denied your request. The Plan says this is 
not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
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 fitting and placing a post in a tooth (D3950), and a surgical procedure for isolation of tooth with rubber dam 
(D3910).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medication assisted methadone treatment (G2067) and 
the take-home supply of methadone (G2078) provided on January 9, 2023, by an OON provider.  
 
You asked the Plan to pay for the assisted methadone treatment and take-home supply. You say that you are a 
walk-in clinic and prior authorization is not required for these services. The Plan denied your request. The Plan 
says these services were 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 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 medication assisted methadone treatment 
(G2067) and the take-home supply of methadone (G2078) provided on January 9, 2023, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal electrical osteogenesis stimulator (E0748). 
 
You asked the Plan to pre-approve a spinal electrical osteogenesis stimulator. You say that the item is 
medically necessary. The Plan denied your request. The Plan says the item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a spinal electrical osteogenesis stimulator (E0748) is 
covered only if any of the following criteria are met: 
1. Failed spinal fusion where a minimum of nine months has elapsed since the last surgery, or 
2. Following a multilevel spinal fusion surgery (see Appendices section), or 
3. Following spinal fusion surgery where there is a history of a previously failed spinal fusion at the same site.  
 
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 spinal electrical osteogenesis 
stimulator. Our reviewer says that the item is not medically necessary. Our physician reviewer found there is no 
indication of spinal fusion in the records submitted.  
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 spinal electrical osteogenesis stimulator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a spinal electrical osteogenesis stimulator (E0748).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation. 
 
You asked the Plan to pre-approve additional non-emergency transportation. You say that you need to get a 
therapy appointment because it is the only way for you to walk again. You also say that your appointment on 
June 28, 2023, had to be cancelled due to transportation issues. The Plan denied your request. The Plan says 
your plan only allows 24 trips. The Plan also says according to the trip log, you have exhausted those trips. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of a total of 24 one-way non-emergency ground transportation trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergency transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for unspecified preventative procedure (D1999), deep sedation/ 
general anesthesia (D9222, D9223) and extractions (D7210 x5) provided on March 8, 2023. 
 
You asked the Plan to pay for unspecified preventative procedure, deep sedation/ general anesthesia, and 
extractions. You say that this should be covered. The Plan denied your request. The Plan says this is not a 
covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
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 unspecified preventative procedure (D1999), deep sedation/ general anesthesia (D9222, D9223) and extractions 
(D7210 x5) provided on March 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the immunotherapy injections provided on January 11, 2023, 
to February 15, 2023. 
 
You asked the Plan to pay for the immunotherapy injections. You say that you are appealing the denial with 
supporting documentation. 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 immunotherapy 
injections provided on January 11, 2023, to February 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each radiation therapy visit provided on 
January 26, 2023, to February 10, 2023. 
 
You asked the Plan to waive the copayment for each radiation therapy visit. You say that you disagree with the 
copayments. 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 a $60 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $60 copayment for each radiation therapy visit. This item/service falls within the 
outpatient diagnostic tests and therapeutic 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. The total amount you owe is $420 ($60 copayment 
x 7 visits = $420). Therefore, we decided that the Plan does not have to waive the copayment for each radiation 
therapy visit provided on January 26, 2023, to February 10, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that the enrollee needs 
transportation to medical appointments. The Plan denied your request. The Plan says this request will exceed 
the maximum number of transportation trips allowed per year. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips (A0120).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an unattended sleep study (95800). 
 
You asked the Plan to pre-approve an unattended sleep study. The Plan denied your request. The Plan says this 
request does not meet the definition of medical necessity. 
 The Plan follows Medicare rules. Medicare rules say that repeat PSG or PSG with CPAP titration may be 
indicated in the circumstances listed in the Medicare rules section of this letter. 
 
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 an unattended sleep study. Our 
reviewer says that an unattended sleep study is not medically reasonable and necessary for the enrollee. Our 
physician reviewer found the enrollee had mild disease on previous sleep study with noncompliance of her 
CPAP machine. A repeat study following weight loss would likely not benefit and show a worsening of her 
OSA. Our reviewer found that the enrollee wanted a repeat study to evaluate for hypoglossal nerve stimulation, 
but would not meet criteria per prior sleep study. Our physician reviewer also found that a repeat study is not 
indicated unless there are worsening symptoms and screening tools. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an unattended sleep study have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an unattended sleep study (95800).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power standing system (E2301). 
 
You asked the Plan to pre-approve a power standing system. You say that this item is deemed to be medically 
necessary and remains necessary for everyday functioning within the enrollee's home setting. The Plan denied 
your request. The Plan says your request is not medically necessary because this option is not considered 
primarily medical in nature. 
 
The Plan must follow Medicare rules. Medicare rules say that a power standing feature (E2301) is non-covered 
because it is not primarily medical in nature. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a power standing system have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a power standing system (E2301).