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

 
We decided that the Plan has to pre-approve the BRAF gene analysis (81210) provided on June 27, 2020. 
 
You asked the Plan to pre-approve the gene analysis. You say that you would like reconsideration because this 
testing is supported by NCCN guidelines. The Plan denied your request. The Plan says that this test is not 
covered for screening purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 the gene analysis. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found because of initial ambiguity in the ultimate cytologic diagnosis, it would meet testing criteria as 
it is medically and reasonable and is not considered screening akin to screening colonoscopy or a1c testing for 
completely asymptomatic individuals.  This person had a MNG and FNA specimens that were not clearly 
benign to the pathologist. 
 
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 gene analysis have been met. Therefore, we decided that the Plan has to pre-
approve the BRAF gene analysis (81210) provided on June 27, 2020.  
 
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 contact lenses (V2530) and fitting (92072) provided on 
December 4, 2019. 
 
You asked the Plan to pay for contact lenses and fitting. You say that this was medically necessary. The Plan 
denied your request. The Plan says this is not supported in the records. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan it covers one routine eye exam and up to $200 towards the purchase of lenses and frames.  
 
 
 
 
We looked at the file and the Plan's rules. Contact lens fitting is not a covered benefit. While the Plan does 
offer a benefit for contact lenses, the records do not document that contact lenses were provided to the enrollee 
on the billed date of service. Based on this information, we decided that the Plan's rules for coverage of contact 
lenses and fitting have not been met. Therefore, we decided that the Plan does not have to pay for contact 
lenses (V2530) and fitting (92072) provided on December 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on June 18, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
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 services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-
network provider on June 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous overnight pulse oximetry provided on July 
18, 2020 by an out of network provider. 
 
You asked the Plan to pay for the continuous overnight pulse oximetry. You say that you thought the provider 
had requested authorization. The Plan denied your request. The Plan says you did not obtain prior authorization 
for the out of network services. 
 
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 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 continuous overnight pulse oximetry provided on July 18, 2020 by an 
out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing services provided to the enrollee on June 29, 
2020. 
 
You asked the Plan to pay for the services. You say that this test was needed on an urgent basis. The Plan 
denied your request. The Plan says prior authorization was required for these services. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found it has not been established that genetic testing in this case would likely impact the management and 
outcome of the enrollee in this case. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for genetic testing services provided to the enrollee on June 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periapical x-ray (D0220) and the crown (D2740) 
provided from September 9, 2020, to September 24, 2020. 
 
You asked the Plan to pay for the dental services. You say that you were specifically told by a plan 
representative that coverage was based on the date of service, not any pre-estimate. You say that this claim 
should be covered. You also say that if this service is not covered, you want a refund of all of the premium that 
you paid on this additional coverage policy that you purchased. The Plan denied your request. The Plan says 
the claim for the periapical x-ray for tooth # 19 was denied as a duplicate. The Plan says that you are not 
financially responsible for the duplicate service. The Plan also says that the crown is not listed as a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the crown not among those covered 
under this benefit. Additionally, you are not financially responsible for the duplicate claim for the periapical x-
ray. Therefore, we decided that the Plan does not have to pay for the periapical x-ray (D0220) and the crown 
(D2740) provided from September 9, 2020, to September 24, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyalgan (J7321). 
 
You asked the Plan to pre-approve Hyalgan. You say that the enrollee has been on the NSAIDS and steroids 
for 3 months. You also say that the enrollee has not had any improvements. The Plan denied your request. The 
Plan says the enrollee has not tried and cannot use Orthovisc and Monovisc. 
 
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 Hyalgan. Our reviewer says that the 
requested drug, Hyalgan, is not medically necessary. Our physician reviewer found the provided 
documentation does not show that the enrollee has tried and failed the required drugs. The reviewer also found 
that there is no indication that the Plan's required drugs 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 Hyalgan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hyalgan (J7321).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the diagnostic bone marrow aspiration (38220), adjacent 
tissue transfer or rearrangement (14041), lower jaw bone graft (21215), and initial observation care (99220). 
 
You asked the Plan to pre-approve the diagnostic bone marrow aspiration, adjacent tissue transfer or 
rearrangement, lower jaw bone graft, and initial observation care. You say that these services are necessary. 
The Plan denied your request. The Plan says these codes are not covered by the Plan. The Plan also says that 
these services are dental in nature, and are not eligible for coverage under the medical benefit. 
 
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, 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 the 
diagnostic bone marrow aspiration (38220), adjacent tissue transfer or rearrangement (14041), lower jaw bone 
graft (21215), and initial observation care (99220).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services you received August 27, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered 
service. 
 
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 a licensed marriage and family 
therapist. This type of provider is not eligible to enroll in the Medicare program. Therefore, we decided that the 
Plan does not have to pay for the services you received August 27, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (71045) provided May 25, 2020. 
 
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says insufficient records were provided to support the claim as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Insufficient records were provided to the plan to determine if the 
claim at issue was a duplicate. Multiple requests were made by the plan for additional records and none were 
provided. Based on this information, we decided that Medicare rules for coverage of the radiology services 
have not been met. Therefore, we decided that the Plan does not have to pay for radiology services (71045) 
provided May 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network 
provider on October 2 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
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 services at issue in this appeal. 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 the medical services provided to you by an out-of-network 
provider on October 2 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy rendered from August 24, 2020 to 
September 17, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be 
covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The 
Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. 
 
We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare 
and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does 
not have to pay for the home infusion therapy rendered from August 24, 2020 to September 17, 2020.  
 
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. 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 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 there are no services available at the LTACH that you require that are not available at 
the health care setting being offered by the health plan. The requested LTACH services are not medically 
necessary, reasonable, and appropriate for your diagnosis and condition 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 long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on June 
30, 2020, to July 2, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you should not be 
responsible for the copayment because you had no idea you were admitted to the hospital. The Plan denied 
your request. The Plan says you have been charged the correct cost sharing amount. 
 
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 $300 
copayment each time you are admitted to an acute care hospital.  
 
You have been asked to pay a $300 copayment for the inpatient hospital stay. The inpatient hospital stay falls 
within the Inpatient hospital care benefit category. The record shows the place of service was an inpatient hospital. 
 
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 inpatient hospital stay provided on June 30, 2020, to 
July 2, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided from April 1, 2020, to April 22, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider is not 
Medicare certified. 
 
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 services provided from April 1, 
2020, to April 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses and related services (V2750, V2100, V2100, 
V2020) purchased on September 22, 2020, from an out-of-network (OON) provider. 
 
You asked the Plan to pay for the eyeglasses and related services. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says no benefit is available for 
services received from an OON provider. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when they are received from an in-network provider. 
 
 
 
We looked at the file and the Plan's rules. 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. Based on this information, we decided that the Plan's rules for coverage of 
the eyeglasses and related services have not been met. Therefore, we decided that the Plan does not have to pay 
for the eyeglasses and related services (V2750, V2100, V2100, V2020) purchased on September 22, 2020, 
from an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first intraoral periapical x-ray, full mouth debridement, 
and surgical extraction provided on July 6, 2020. 
 
You asked the Plan to pay for the first intraoral periapical x-ray, full mouth debridement, and surgical 
extraction. You say that you would like these services to be reconsidered for payment. The Plan denied your 
request. The Plan says these services 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 Plan?s 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 the first 
intraoral periapical x-ray, full mouth debridement, and surgical extraction provided on July 6, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on April 23, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was 
submitted after the timely filing limit. 
 
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 the services was not filed until September 14, 2020. 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 the services provided on April 23, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the HPV testing (87624) provided on 
October 1, 2020. 
 
You asked the Plan to waive the copayment for the HPV testing. You say that you would like reconsideration 
of the copayent assessed for your routine PAP. The Plan denied your request. The Plan says this cost sharing 
amount has been applied 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 $10 
copayment for outpatient diagnostic tests.  
 
You have been asked to pay a $10 copayment for the HPV testing. The HPV testing falls within the outpatient 
diagnostic tests 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 HPV testing (87624) 
provided on October 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite (D2332) provided on July 14, 
2020. 
 
You asked the Plan to pay for the resin-based composite. You say that you would like to know why this 
procedure was not covered. The Plan denied your request. The Plan says this service is not a covered benefit 
under your dental plan. 
 
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, 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 the resin-
based composite (D2332) provided on July 14, 2020.