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

 
We decided that the Plan does not have to pre-approve 24 additional acupuncture sessions, physical therapy 
services and infrared therapy. 
 
You asked the Plan to pre-approve additional acupuncture sessions, physical therapy services and infrared 
therapy. You say that the requested services are a necessity for your care. The Plan denied your request. The 
Plan says the requested services are 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 physical therapy services. Our reviewer 
says that physical therapy services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the provided documentation does not clearly indicate that this treatment 
is furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of your 
condition or to improve the function of a malformed body member or furnished in a setting appropriate to your 
medical needs and condition. The documentation does not reveal evidence of clear goals, treatment plans, a 
detailed musculoskeletal and neuromuscular exam indicating deficits that require formal physical therapy 
treatments. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy services have not been met. Furthermore, we find that the Plan 
has already approved 20 acupuncture treatments, which is the annual maximum. We also find that infrared 
therapy is non-covered. Therefore, we decided that the Plan does not have to pre-approve 24 additional 
acupuncture sessions, physical therapy services and infrared therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit evaluation provided on February 23, 2023. 
 
You asked the Plan to pay for the home visit evaluation. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the home visit 
evaluation provided on February 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the DecisionDx DiffDx-Melanoma gene expression test. 
 
You asked the Plan to pre-approve the DecisionDx DiffDx-Melanoma gene expression test. You say that this 
testing is medically necessary. The Plan denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as not covered. Based on this 
information, we decided that Medicare rules for coverage of the DecisionDx DiffDx-Melanoma gene 
expression test have not been met. Therefore, we decided that the Plan does not have to pre-approve the 
DecisionDx DiffDx-Melanoma gene expression test.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nine (9) months for the home ventilator (E0466). 
 
You asked the Plan to pre-approve the ventilator. You say that the ventilator is medically necessary. The Plan 
denied your request. The Plan says the ventilator is not medically necessary. 
 
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 the ventilator. Our physician reviewer 
found the provided records document that the home ventilator is being requested for use in average volume 
assured pressure support (AVAPS) mode with auto-EPAP (AE) which could be provided by a bilevel positive 
airway pressure (BiPAP) device with AVAPS and a back-up rate. Provided records do not document trial and 
failure of a BiPAP device with AVAPS and a back-up rate. The provided records in this case do not provide 
adequate detailed information to meet Medicare criteria for coverage of a ventilator as opposed to a BiPAP 
device with AVAPS and a back-up rate. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve nine (9) months for the home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 1 standard power operated vehicle (K0800). 
 
You asked the Plan to pre-approve a group 1 standard power operated vehicle. You say that you need the 
electric scooter because you have had 3 reconstructive surgeries, and you cannot stand or walk on your leg for 
more than 30 minutes because it becomes excruciating for you. The Plan denied your request. The Plan says 
there is no evidence that a power operated vehicle is medically necessary. 
 
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.  
 
 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 standard power operated 
vehicle. Our reviewer says that you do not meet the coverage criteria for a group 1 standard power operated 
vehicle. Our physician reviewer found the mobility evaluation indicates that you can ambulate household 
distances with the use of rollator and accomplish mobility related activities of daily living in the home. You 
have access to the community with a motor vehicle and can use a rollator for short community distances. Our 
reviewer also found that your home is not accessible for the requested power scooter. 
 
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 standard power operated vehicle have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 1 standard power operated vehicle (K0800).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets LTACH admission 
criteria, and their ongoing medical care warrants an LTACH level of care to achieve a safe and sustainable 
discharge. The Plan denied your request. The Plan says the enrollee does not meet Medicare guidelines for care 
in an LTACH.  
 
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 all medically necessary care is being provided in the current acute care setting.  
 There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the Plan. The Plan has approved ongoing care in the current acute care setting. The 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 19, 2023, by an 
OON provider.  
 
You asked the Plan to pay for the lab services. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says this service was not authorized. 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the item/service 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 the item/service. Therefore, 
we decided that the Plan does not have to pay for the laboratory services provided on January 19, 2023, by an 
OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pontics (D6240 x 2) and retainer crowns (D6740 x 4) 
provided on August 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denial. The Plan denied 
your request. The Plan says these services are either not covered under your dental plan or are part of a non-
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. 
 
 
  The records show your provider used an inappropriate code, D6068 should have been billed instead of D6740. 
Additionally, due to D6068 being a non-covered service pontics are not eligible for coverage because they are 
part of a non-covered service. Therefore, we decided that the Plan does not have to pay for the pontics (D6240 
x 2) and retainer crowns (D6740 x 4) provided on August 10, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mental health visit provided on November 11, 2022, by 
an OON provider.  
 
You asked the Plan to pay for the mental health visit. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says this service was not authorized. 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the item/service 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 the item/service. Therefore, 
we decided that the Plan does not have to pay for the mental health visit provided on November 11, 2022, by an 
OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits provided on May 18, 2022, through 
December 10, 2022. 
 
You asked the Plan to pay for the office visits. You say that the services should be covered. The Plan denied 
your request. The Plan says this provider is not certified with 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 office visits provided on May 18, 
2022, through December 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller with harness upgrade, 
electronic connection, and power elevating leg rests for a power wheelchair (PWC). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules say that power elevating leg rests are covered when specific criteria are 
met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records show that the enrollee has 
use of the upper extremities and can operate and control the power options using the switches in the approved 
wheelchair. There is no documentation of a condition that meets the criteria for coverage of the power 
elevating leg rests. The services are therefore not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an expandable controller with harness upgrade, electronic connection, and power elevating 
leg rests for a power wheelchair (PWC).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99214) and Leuprolide acetate 7.5 mg (J9217) 
provided on September 7, 2021. 
 
You asked the Plan to pay for an office visit and an administered medication. You say that you disagree with 
the denial and have submitted medical records for review. The Plan denied your request. The Plan says the 
documentation submitted does not show the billed services were supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99214 is an office or other outpatient visit for the 
evaluation and management of an established patient, which requires a medically appropriate history and/or 
examination and moderate level of medical decision making. When using time for code selection, 30-39 
minutes of total time is spent on the date of the encounter and the CPT Code Manual definition of code J9217 
is a Leuprolide acetate (for depot suspension), 7.5 mg. 
 
We find that CPT codes 99214 and J9217 are not supported in the medical record. Specifically, the medical 
records submitted do not indicate that 30-39 minutes were spent on the date of the encounter. Additionally, the 
documentation submitted does include how many milligrams of Leuprolide acetate were administered. We are 
unable to validate the number of units billed. A request for additional medical records and documentation was 
requested by the Plan and no new medical records were received. Based on this information, we decided that 
Medicare rules for coverage of an office visit and an administered medication have not been met. Therefore, we 
decided that the Plan does not have to pay for an office visit (99214) and Leuprolide acetate 7.5 mg (J9217) 
provided on September 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit for the evaluation and management provided on 
February 21, 2023. 
 
You asked the Plan to pay for a home visit for the evaluation and management. You say that the services 
should be covered. 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 a home visit for the 
evaluation and management provided on February 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the third-party office visit for the purpose of employment 
(99214), provided on April 25, 2023. 
 
You asked the Plan to pay for the office visit. You say that the service should be covered. The Plan denied your 
request. The Plan says physical exams and other services required by third parties for such things as obtaining 
or maintaining employment are not covered. 
 
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 the office visit have not been met. Therefore, we decided that the Plan does not have to pay for the 
third-party office visit for the purpose of employment (99214), provided on April 25, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs and waive the copayment for the 
emergency room services provided on February 23, 2023, through February 28, 2023. 
 
You asked the Plan to pay for the self-administered drugs and waive the copayment for the emergency room 
services. You say that the services should be covered. The Plan denied your request. The Plan says this cost 
sharing was charged correctly, and self-administered drugs are not covered. 
 
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 $95 
copayment for emergency care. Medicare Part B generally does not pay for drugs that are usually self-
administered by the patients who take them.  
 
You have been asked to pay a $95 copayment for the emergency room services. This service falls within the 
emergency care 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. Medicare Part B generally does not pay for drugs that are usually self-administered by the patients who 
take them. Therefore, we decided that the Plan does not have to pay for the self-administered drugs and waive 
the copayment for the emergency room services provided on February 23, 2023, through February 28, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray provided on December 27, 2022. 
 
You asked the Plan to pay for the chest x-ray. You say that at the time of service the enrollee was residing in a 
nursing home. 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 chest x-ray provided 
on December 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye surgery provided on March 02, 2023. 
 
You asked the Plan to pay for the eye surgery. You say that you were not told about the network of providers 
for the Plan. 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 eye surgery provided 
on March 02, 2023.