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

 
We decided that the Plan does not have to pre-approve foot surgery to be performed at an outpatient hospital. 
 
You asked the Plan to pre-approve surgery at an outpatient hospital. You say that the service is necessary. The 
Plan denied your request. The Plan says the service is not necessary. The Plan states the enrollee can get the 
surgery at an ambulatory surgical center. 
 
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 surgery at an outpatient hospital. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the detailed documentation is not evident regarding a significant medical 
history that would place this specific enrollee at an increased risk for perioperative complications that would 
not be able to be safely addressed at an ambulatory surgery center. Risk factors are not evident that would place the enrollee at high risk for an unplanned inpatient admission associated with this procedure. No compelling 
rationale is presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. Therefore, the surgery is not necessary to be performed in an outpatient hospital and the enrollee can 
receive the services at an ambulatory surgical center that the Plan approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of surgery at an outpatient hospital have not been met. Therefore, we decided that 
the Plan does not have to pre-approve foot surgery to be performed at an outpatient hospital.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete denture - mandibular (D5120), and reline 
complete maxillary denture (indirect) (D5750) provided on July 5, 2022, and December 20, 2022. 
 
You asked the Plan to pay for the complete denture and reline complete denture. You say that you feel that 
these should have been covered by my plan, or at least a portion of it The Plan denied your request. The Plan 
says D5120 and D5750 are not listed as covered services. 
 
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 a 
complete denture - mandibular (D5120), and reline complete maxillary denture (indirect) (D5750) provided on 
July 5, 2022, and December 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve TransCranial Magnetic Stimulation (TMS). 
 
You asked the Plan to pre-approve TMS. You say that the services are necessary. The Plan denied your request. 
The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that retreatment may be considered for patients who met 
the guidelines for initial treatment and subsequently developed relapse of depressive symptoms if the patient 
responded to prior treatments as evidenced by a greater than 50% improvement in standard rating scale 
measurements for depressive symptoms. 
 
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 TMS. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found based on the information provided, you do 
not meet the clinical criteria for the use of Transcranial Magnetic Stimulation (TMS) therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TMS have not been met. Therefore, we decided that the Plan does not have to 
pre-approve TransCranial Magnetic Stimulation (TMS).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for surgical placement of implant body: endosteal implant 
(D6010), bone graft at time of implant placement (D6104), and  extraction, erupted tooth or exposed root 
(elevation and/or forceps removal) (D7140) provided on November 29, 2022. 
 
 
 You asked the Plan to pay more for the dental services. 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. You are responsible for paying the full cost of services that arent covered by 
our Plan, either because they are not covered services or plan rules were not followed. Therefore, the claim was 
paid correctly up to the annual maximum allowable for an out-of-network provider. 
 
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 placement of implant body: 
endosteal implant (D6010), and bone graft at time of implant placement (D6104) are not among those covered 
under this benefit. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for surgical placement of implant body: 
endosteal implant (D6010), bone graft at time of implant placement (D6104), and  extraction, erupted tooth or 
exposed root (elevation and/or forceps removal) (D7140) provided on November 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the electrocardiogram (EKG) provided on 
December 01, 2022. 
 
You asked the Plan to waive the copayment for the electrocardiogram (EKG). You say that there were issues 
with this claim and you should have a $0 copayment. 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 $40 
copayment for outpatient hospital services. 
 
You have been asked to pay a $40 copayment for the electrocardiogram (EKG). This item/service falls within 
the outpatient hospital services 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 records show the EKG was provided at an outpatient hospital. Therefore, 
we decided that the Plan does not have to waive the copayment for the electrocardiogram (EKG) provided on 
December 01, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 facet joint injections. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the medical records do not show that you have tried/failed non-invasive conservative 
management. The requested repeat facet joint injections are not medically reasonable or necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on November 23, 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 on November 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0676). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested device. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
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, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pre-approve a pneumatic compression device (E0676).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on December 29, 2022. 
 
You asked the Plan to pay for the physician's services. 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 physician's services provided on December 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement power wheelchair (E0955, E1002, E1028, 
E2361, E2603, K0835). 
 
You asked the Plan to pre-approve the replacement power wheelchair. You say that the existing wheelchair is 
broken and a replacement is medically necessary. The Plan denied your request. The Plan says no records were 
provided to show that the existing wheelchair is inoperable or unable to be repaired. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee has a power wheelchair. The replacement wheelchair serves the same purpose 
as the existing power wheelchair. Therefore, we decided that the Plan does not have to pre-approve a 
replacement power wheelchair (E0955, E1002, E1028, E2361, E2603, K0835).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for COVID-19 tests provided on August 10, 2021, and  
January 18, 2022. 
 
You asked the Plan to pay for the COVID-19 tests. You say that the COVID-19 tests were required for you to 
go to Canada to check on your properties and should be paid. The Plan denied your request. The Plan says the 
Plan does not cover claims that are for people traveling to other states/countries during the pandemic as 
pandemic control. 
 
The Plan must follow Medicare rules. Medicare rules say that the routine physical checkup exclusion applies to 
examinations required by third parties such as insurance companies, business establishments, or Government 
agencies. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the COVID-19 tests have not been met. Therefore, we decided that the Plan does not have to pay 
for COVID-19 tests provided on August 10, 2021, and January 18, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ultrasound provided on May 5, 2022, by an OON 
provider. You asked the Plan to pay for the ultrasound. You say that you are asking for reconsideration of the denied 
claim. The Plan denied your request. The Plan says that this service is 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 Plan contract also says that the enrollees POS benefit does 
not apply to an out-of-network ultrasound. 
 
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 an ultrasound provided on May 5, 2022, by an 
OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on September 29, 2022. 
 
You asked the Plan to pay for the wound care supplies. You say that this patient has been treated for their 
wounds and billing separately for these supplies is appropriate. 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 wound care supplies provided on September 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve FoundationOne CDx and Reflex FoundationOne Liquid 
CDx testing to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve laboratory tests. You say that this test must be performed by a specific 
laboratory. The Plan denied your request. The Plan says the enrollee's benefits only cover out-of-network 
services in certain limited circumstances, which have not been met in this case. Specifically, the Plan has in-
network laboratories available who are able to perform the specified tests. 
 
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 
FoundationOne CDx and Reflex FoundationOne Liquid CDx testing 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 pre-approve abutment supported porcelain fused to metal crown 
(D6060), interim partial denture (maxillary) upper arch (D5820) as they are not covered services. The crown-
porcelain fused to predominantly base metal (D2751) has met its frequency limit and pontic-porcelain fused to 
base metal Tooth 3, 8, 9, & 10 (D6241) was found too not be medically necessary. 
 
You asked the Plan to pre-approve abutment, partial denture, crown and pontic. You say that this is medically 
necessary. The Plan denied your request. The Plan says fixed bridges are available and limited to anterior maxillary three-unit bridges (one missing maxillary tooth), and anterior mandibular bridges up to four units 
(two missing adjacent mandibular teeth). Bridges will only be covered if no other teeth are missing in the same 
arch other than 3rd molars. Double abutments are not authorized for fixed prosthetics. Our dentist reviewed the 
x-rays performed and determined that there are other teeth missing. 
 
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 Plan covers crown and 
pontic when the services are medically necessary and reasonable.  
 
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 crown and pontic. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the service is not medically 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of abutment, partial denture, crown and pontic have not been met. Therefore, we 
decided that the Plan does not have to pre-approve abutment supported porcelain fused to metal crown 
(D6060), interim partial denture (maxillary) upper arch (D5820), crown-porcelain fused to predominantly base 
metal (D2751) and pontic-porcelain fused to base metal Tooth 3, 8, 9, & 10 (D6241).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nurse practitioner services provided on January 12, 2023. 
 
You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says the 
services were not urgent or emergent. It was also determined the services rendered could have been provided 
by a participating provider under the members Plan. 
 
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 nurse practitioner services provided on January 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walker, enclosed, four sided framed, rigid or folding, 
wheeled with posterior seat (E0144). 
 
You asked the Plan to pre-approve a walker. You say that the enrollee needs a walker to help with mobility. 
The Plan denied your request. The Plan says the requested item is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a walker have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
walker, enclosed, four sided framed, rigid or folding, wheeled with posterior seat (E0144).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 13, 2022. 
 
You asked the Plan to pay for the office visit. You say that you are asking for reconsideration of the denied 
claim. The Plan denied your request. The Plan says that the provider 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 an office visit provided on July 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair lift (E1399). 
 
You asked the Plan to pre-approve a stair lift. You say that you feel this is medically necessary for you to have. 
You have a hard time going up and down stairs and would also like this to prevent falls. The Plan denied your 
request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a stair lift (E1399).