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

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on May 4, 2020. 
 
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 subsequent nursing facility care provided on May 4, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET Brain scan (78608). 
 
You asked the Plan to pre-approve a PET Brain scan (78608). You say that the requested PET Brain scan 
(78608) is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria 
for the requested PET Brain scan (78608). 
 
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 a PET Brain scan (78608). Our 
reviewer says that the enrollee does not meet criteria for the requested PET Brain scan (78608). Our physician 
reviewer found the member in this case is noted to have a history of progressive memory impairments of 
indeterminate origin/cause. Her treating provider has requested prior authorization for the performance of a 
PET/CT scan of the brain. 
 
According to the applicable NCD, PET of the brain may be covered when all of the requirements in the NCD 
have been satisfied. In this case the medical records provided for review did not support that the member met 
the diagnostic criteria for both AD and FTD. Rather, the notes did not readily suggest the presence of either 
condition (let alone both). As the NCD requires that a patient meet diagnostic criteria for both AD and FTD 
and the notes provided for review did not show that this initial requirement for coverage had been met, this 
service cannot be determined to be medically necessary at this time. 
 
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 PET brain scan (78608) have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a PET brain scan (78608).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for orthotics (L1851, L2397, L2385) provided on April 12, 
2020. 
 
You asked the Plan to pay for orthotics. You say that the documentation supports the billed items. The Plan 
denied your request. The Plan says a valid proof of delivery has not been submitted. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid of delivery for the supplies provided in this case. The documentation in the 
file shows a delivery date of April 3, 2020. The items at issue were billed with a date of service of April 12, 
2020. The record shows that the Plan made several attempts to obtain the necessary documentation without 
success. Therefore, we decided that the Plan does not have to pay for orthotics (L1851, L2397, L2385) 
provided on April 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical assistant services on an allograft (20931) provided 
on March 14, 2020. 
 
You asked the Plan to pay for surgical assistant services on an allograft. You say that you did not have control 
over who performed these services. The Plan denied your request. The Plan says surgical assistants are not 
covered for this procedure. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT code 
20931. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means 
that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based 
upon this information, we find that Medicare coverage criteria for surgical assistant services on an allograft 
have not been met. Therefore, we decided that the Plan does not have to pay for surgical assistant services on 
an allograft (20931) provided on March 14, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gemcitabine and Vinorelbine Tartrate chemotherapy. 
 
You asked the Plan to pre-approve Gemcitabine and Vinorelbine Tartrate chemotherapy. You say that the 
requested Gemcitabine and Vinorelbine Tartrate chemotherapy is medically necessary. The Plan denied your 
request. The Plan says the requested Gemcitabine and Vinorelbine Tartrate chemotherapy is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Gemcitabine and Vinorelbine Tartrate 
chemotherapy. Our reviewer says that the requested Gemcitabine and Vinorelbine Tartrate chemotherapy is not 
medically necessary. Our physician reviewer found the enrollee is diagnosed with malignant neoplasm of head, 
face and neck. The request for Gemcitabine and Vinorelbine Tartrate combo is not FDA approved for the 
enrollee's diagnosis. The use is not supported by one of the major drug compendia or by clinical research that 
appears in a CMS-approved medical journal for Gemcitabine and Vinorelbine Tartrate for the enrollee's 
diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gemcitabine and Vinorelbine Tartrate chemotherapy have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Gemcitabine and Vinorelbine Tartrate 
chemotherapy.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the advanced imaging services, CT scan 
provided July 2, 2020. 
 
You asked the Plan to waive the copayment for the advanced imaging services. You say that you are being 
charged over $90 for an ER visit. The Plan denied your request. The Plan says this claim was processed and the 
correct copayment was applied. 
 
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 $225 
copay for each Medicare covered advanced imaging service.  
 
You have been asked to pay $223.66 for the CT scan. The CT scan 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. Therefore, we decided that the Plan does not have to waive the copayment for 
the advanced imaging services, CT scan provided July 2, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on January 28, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for laboratory testing. You say that you are appealing with medical records. The 
Plan denied your request. The Plan says the denial of payment for these services is correct, because this 
provider is out-of-network with the Plan and the ordering provider is also out-of-network with the 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 has network providers 
available who can provide 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 medical services provided on January 28, 2020 
by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab work provided on February 27, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and approved for 
payment. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that 
the referring provider is also out-of-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan 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 lab work provided on February 27, 2020 by an out 
of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and the prophylaxis 
(D1110) provided on June 2, 2020. 
 
You asked the Plan to pay for the dental services. You say that you do not understand how your benefit has 
been exhausted. You say that your claims have been denied without merit. You also say that these services 
should be covered. The Plan denied your request. The Plan says the annual maximum benefit of $500 has been 
exceeded. The Plan says that any remaining charges after the annual maximum has been reached are your 
responsibility. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and the services you received are listed 
as covered, the annual maximum benefit of $500 has been exceeded.  
 
Date of Service CPT Code Billed Allowed Plan Paid Your Responsibility 
1/28/2020 D0150 $106 $61 $58.50 $2.50 
 D0210 $160 $160 $0 $160 
 D0110 $111 $111 $0 $111 
3/3/2020 D2750 $1,376 $883 $441.50 $441.50 
 D2950 $328 $204 $102 $102 
6/2/2020 D0120 $61 $61 $0 $61 
 D1110 $111 $111 $0 $111 
TOTAL:    $602 $989 
 
 
 
The record shows that the Plan has already paid more than the annual maximum and therefore will not pay any 
additional amount for the services you received. Therefore, we decided that the Plan does not have to pay for 
the periodic oral evaluation (D0120) and the prophylaxis (D1110) provided on June 2, 2020.  
 
Your complaint about being given misinformation from a Plan representative is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing services provided on June 15, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for skilled nursing services. You say that prior authorization couldn't be obtained 
because of COVID-19. The Plan denied your request. The Plan says prior authorization was not obtained by the 
facility or the provider for these services; therefore, payment has been correctly denied. 
 
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 
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 skilled nursing services provided on June 15, 2020 
by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room (ER) services you 
received on May 19, 2020. 
 
You asked the Plan to waive the copayment for the ER services. You say that you shouldn't have to pay this 
copayment because you still had COVID-19 after this ER visit. The Plan denied your request. The Plan says 
you were charged this copayment 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 $90 
copayment for emergency room services.  
 
You have been asked to pay a $90 copayment for the ER services. This copayment applies regardless of the 
reason for the ER visit. 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. 
Therefore, we decided that the Plan does not have to waive the copayment for emergency room (ER) services 
you received on May 19, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on June 25, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the MRI (72148). You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says utilization of network providers is required 
unless out-of-network services are pre-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 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 has network providers 
available who can provide 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 medical services provided on June 25, 2020 by 
an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 24, 2020. 
 
You asked the Plan to pay for the genetic testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services provided are not a covered benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The genetic testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover 
this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the genetic 
testing provided on March 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided from May 15, 2020 to May 17, 
2020. 
 
You asked the Plan to pay for the medical services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the services billed are not supported in the medical record. Specifically, these services were billed 
with revenue (REV) code 0637. This REV code is on the statutory exclusion list or the Revenue code is 0637 
with SI of E when submitted without a HCPCS code. REV code 637 has a status indicator of E and E1. 
Providers should use explicit procedure or HCPCS coding to describe services and items they deliver, even 
when submitting these items as non-covered. Based on this information, we decided that Medicare rules for 
coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay 
for the medical services provided from May 15, 2020 to May 17, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided on 
March 20, 2020. 
 
You asked the Plan to pay for genetic testing. You say that the enrollee's treating physician ordered this testing 
to determine if there was a more effective therapy to treat the enrollee's condition. The Plan denied your 
request. The Plan says the denial of payment for this testing is correct, because this testing was not billed with 
the appropriate coding. 
 
The Plan must follow Medicare rules. Medicare rules say that CGP testing must be billed with CPT code 81479 
for date of service March 20, 2020. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for 
comprehensive genomic profile (CGP) testing provided on March 20, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient mental health services (90832) provided on 
January 30, 2020. 
 
You asked the Plan to pay for the outpatient mental health services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says there were network providers available. The services 
were not emergent or pre-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 has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the outpatient mental health services (90832) provided on January 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS HF System. 
 
You asked the Plan to pre-approve a CardioMEMS HF System. You say that the requested CardioMEMS HF 
System is medically necessary. The Plan denied your request. The Plan says the requested CardioMEMS HF 
System is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CardioMEMS HF System. Our 
reviewer says that the requested CardioMEMS HF System is not medically necessary. Our physician reviewer 
found the enrollee is with a history of nonischemic cardiomyopathy, paroxysmal atrial fibrillation, ICD 
placement, obesity, chronic kidney disease and NYSHA Class III congestive heart failure with mildly reduced 
LV ejection fraction (LVEF 44%) requiring hospitalization. 
 
In this circumstance therapy change based on data obtained from a CardioMEMs device has been demonstrated 
in only one trial to help reduce hospital readmission compared to standard medical therapy.  Moreover, 
concerns have been raised about potential bias in this trial calling into question the results.   Therefore, the 
efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and not 
recommended in current guidelines for the treatment of heart failure.  Medicare coverage criteria are not met 
since the device should still be considered experimental or investigational. 
 
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 CardioMEMS HF System have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a CardioMEMS HF System.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Supartz. 
 
You asked the Plan to pre-approve Supartz. You say that the requested Supartz is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail Euflexxa and Synvisc first. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Supartz. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the enrollee is with osteoarthritis 
of the right knee. His provider has requested Supartz. The review indicates that the Plan requires a trial of drugs 
Euflexxa and Synvisc first before they will approve the requested drug. In this case, the enrollee has not tried 
and failed the required drug(s). There is no documentation provided indicating that the Plan?s required drug(s) 
would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Supartz have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Supartz.