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

 
We decided that the Plan does not have to pre-approve diabetic supplies to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve diabetic supplies. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the enrollees network primary care provider (PCP) or plan must give 
the enrollee approval in advance before the enrollee can use providers not in the plan's network. This is called 
giving you a "referral." 
 
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 
diabetic supplies to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for chiropractic care on May 12, 2023. 
 
You asked the Plan to waive the deductible for chiropractic care. You say that you say that you have met your 
deductible. 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. Your 
contract with the Plan says that there is a $10,000 out-of-network deductible which applies to chiropractic 
services.  
 
The item or service you asked the Plan to waive the deductible for falls within the chiropractic services benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $10,000 
deductible which applies to chiropractic services. This cost sharing is a contractual obligation that had not been 
met at the time chiropractic care was received on May 16, 2023. Therefore, we decided that the Plan does not 
have to waive the deductible for chiropractic care on May 12, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on April 24, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for home health services. You say that you would like to request reconsideration of 
the denied claim and that the services requested are medically necessary. The Plan denied your request. The 
Plan says this provider is not a network provider and we have 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 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 home health services provided on April 24, 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 15 physical therapy visits to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve 15 physical therapy visits. You say that you are requesting reconsideration 
of the denied authorization. The Plan denied your request. The Plan says this service is available with in-
network providers. 
 
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 
15 physical therapy visits to be provided by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the placement of intra-socket biological dressing to aid 
in hemostasis or clot stabilization, per site (D7922). 
 
You asked the Plan to pre-approve the placement of intra-socket biological dressing. The Plan denied your 
request. The Plan says this is not a covered expense under 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 service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
placement of intra-socket biological dressing to aid in hemostasis or clot stabilization, per site (D7922).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET scan to be provided by an OON provider.  
 
You asked the Plan to pre-approve a PET scan. You say that you are requesting reconsideration of the denied 
service. The Plan denied your request. The Plan says the service was not approved. 
 
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 PET scan to be provided by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2750) for tooth #20. 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within your dental benefits. 
 
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 a 
crown (D2750) for tooth #20.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical placement of the implant body (D6010), an 
abutment supported porcelain fused to metal crown (D6061) and a custom fabricated abutment (D6057). 
 
You asked the Plan to pre-approve a surgical placement of the implant body (D6010), an abutment supported 
porcelain fused to metal crown (D6061) and a custom fabricated abutment (D6057). You say that these services 
were covered last year so you are not sure why they are no longer covered. You also say you do not understand 
why this is not covered since this is an in-network provider. The Plan denied your request. The Plan says the 
requested codes are not listed in the EOC. The Plan also says therefore, they are 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
surgical placement of the implant body (D6010), an abutment supported porcelain fused to metal crown 
(D6061) and a custom fabricated abutment (D6057).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Mako RATKA device. 
 
You asked the Plan to pre-approve the Mako RATKA device. You say that the device is medically necessary.  
The Plan denied your request. The Plan says the Mako RATKA device is not medically necessary. The Plan 
says the device is considered experimental and unproven.  
 
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 the Mako RATKA device. Our 
reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was being treated for left knee tricompartmental osteoarthritis. However, 
there are no large volume, long-term/high-quality clinical studies that confirm the clinical benefits (ultimate 
outcomes of functional improvement and pain reduction) of computer-assisted surgery over standard surgical approaches in total knee arthroplasty. Therefore, the requested MAKOplasty (robotic assisted) total knee 
arthroplasty is 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 the Mako RATKA device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Mako RATKA device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics.  
 
You asked the Plan to pre-approve foot orthotics. You say that you have pain when you walk, and these inserts 
would really help. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided by a chiropractor on August 9, 2023. 
 
You asked the Plan to pay for the office visit. You say that you referred and told to go to a chiropractor due to 
the pain you have been having in your back. The Plan denied your request. The Plan says that the only covered 
chiropractic service is manual manipulation of the spine. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for an office visit provided by a chiropractor on August 9, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from April 2, 2023, through 
April 7, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the acute inpatient hospital care provided 
was not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the 
documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer 
found that this enrollee presented for an evaluation of a progressive generalized weakness and fatigue as well 
as right hip pain. He was found to have a lung mass with metastatic disease to the brain as well as an L2 
fracture. The decision was made to admit him to an inpatient level of care. The documentation supports an 
inpatient level of care. The documentation implicates failure to thrive in the setting of a newly diagnosed 
metastatic lung cancer. At the time of admission, the enrollee's symptoms were progressive and not controlled. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
the acute inpatient hospital care provided from April 2, 2023, through April 7, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the lower extremity prosthesis, and related items to be 
provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the lower extremity prosthesis, and related items. You say that these items 
are medically necessary. The Plan denied your request. The Plan says enrollees must receive their care from a 
network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the 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 
the lower extremity prosthesis, and related items to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the psychotherapy sessions and treatment to be provided 
by an OON provider.  
 
You asked the Plan to pre-approve 30 psychotherapy sessions and treatment. You say that you are requesting 
reconsideration of the denied authorization. The Plan denied your request. The Plan says this service is 
available with in-network providers. 
 
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 
the psychotherapy sessions and treatment to be provided by an OON provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medication assisted treatment provided on June 26, 2023. 
 
You asked the Plan to pay for medication assisted treatment. You say that a referral or authorization is not 
required. 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 medication assisted 
treatment provided on June 26, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of the lumbar spine. 
 
You asked the Plan to pre-approve an MRI of the lumbar spine. You say that the requested scan is medically 
necessary. The Plan denied your request. The Plan says the MRI requested is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRI of the lumbar spine. Our 
reviewer says that that the requested MRI does not meet the necessary criteria to be approved. Our physician 
reviewer found that there is no documentation submitted to suggest a medical necessity for the requested MRI 
of the lumbar spine. 
 
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 MRI of the lumbar spine have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an MRI of the lumbar spine.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the prostate specific antigen (PSA) testing received on June 20, 2023. 
 
You asked the Plan to pay for the PSA testing. You say that you had elevated antigen levels plus a family 
history and was advised by your provider to have a repeat test at 6 months. The Plan denied your request. The 
Plan says that the services received are not a covered benefit. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were provided the PSA testing by a contract provider. The file does not show that the Plan provided notice 
that the PSA testing would not be covered. Under Medicare rules, this means the PSA testing is considered 
approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for the prostate specific 
antigen (PSA) testing received on June 20, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional hours through Papa Pals in-home support 
benefit. 
 
You asked the Plan to pay for the additional hours through Papa Pals in-home support benefit. You say that you 
would like the plan to approve additional in-home support service hours due to continued household assistance 
needed in the home and companionship after open heart surgery. The Plan denied your request. The Plan says 
the benefit has been exhausted. 
 
The Plan must follow Medicare rules. Medicare rules say that in-home support services are not typically 
covered. However, the Plan offers an in-home support services benefit that exceeds Medicare coverage. For 
that reason, the Plans coverage rules apply in this case.   
 
Though the Plan offers an in-home support service in excess of Medicare coverage, certain limitations apply. 
The record shows your benefit for the requested item or service was exhausted between January 12, 2023, to 
June 20, 2023. Therefore, we decided that the Plan does not have to pay for the additional hours through Papa 
Pals in-home support benefit.
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 say that you want to improve your 
condition through Chinese medication. The Plan denied your request. The Plan says the enrollee must receive 
their care from a network provider (for more information about this, see Section 2 of Chapter 3). In most cases, 
care the enrollee receives from an out-of-network provider (a provider who is not part of the plans network) 
will not be 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 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.