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

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. 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 Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found based on the medical records provided daily 
skilled services are not required. This enrollee does not require the services on an inpatient basis, in a skilled 
nursing facility setting. Services in a long-term care facility on a part time basis or in the home with home 
health services appears appropriate 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayment for the panoramic x-rays provided on June 8, 2020. 
 
You asked the Plan to waive the copayment for the panoramic x-rays. You say that you need assistance with 
your bills. You say you have never had a large health insurance claim. The Plan denied your request. The Plan 
says that 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. Your 
contract with the Plan says that enrollees must pay a $0 copayment for each in-network Medicare-covered 
standard x-ray service.  
 
The Plan says you must pay an $18.36 copayment for the panoramic x-rays. Based on the Plan contract, 
however, you cannot be asked to pay more than a $0 copayment for the panoramic x-rays. Therefore, we 
decided that the Plan has to waive the copayment for the panoramic x-rays provided on June 8, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent 
nor urgent and prior authorization was not obtained to provide out-of-network care. 
 
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 physician services provided by an out of 
network (OON) provider.
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 March 27, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are 
available in-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 has network providers 
available who can provide 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 March 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the annual wellness exam (99397) provided August 24, 2020. 
 
You asked the Plan to pay for the annual wellness exam. You say that you would not go to the doctor except 
once a year for a physical. The denied appointment was for a referral to a surgeon for bilateral inguinal hernia 
surgery. The Plan denied your request. The Plan says this service exceeds the benefit frequency limitation. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The plan?s coverage rules apply in this case This service is covered once a year. The 
records show that this service was provided January 2, 2020. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that you have exhausted the 
Plan maximum benefit  coverage  for annual wellness exams. Therefore, we decided that the Plan does not 
have to pay for the annual wellness exam (99397) provided August 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic X-ray (D0330) provided on August 11, 2020. 
 
You asked the Plan to pay for the panoramic X-ray. You say that you were not aware that the X-rays would not 
be covered. The Plan denied your request. The Plan says you have exhausted your benefits for panoramic X-
rays. 
 
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. The Plan covers the panoramic 
X-ray once every five years.  
 
We looked at the file and Medicare rules. The file indicates that the Plan last covered panoramic X-rays in 
February 2020. This means that when you received the panoramic X-ray on August 11, 2020, you had already 
exhausted your benefits.Based on this information, we decided that the Plan's rules for coverage of the 
panoramic X-ray have not been met. Therefore, we decided that the Plan does not have to pay for the 
panoramic X-ray (D0330) provided on August 11, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve AJOVY 225 mg/1.5 ml syringe. 
 
You asked the Plan to pre-approve AJOVY. You say that this service is medically necessary for the enrollee. 
The Plan denied your request. The Plan says your Medicare Advantage plan does not cover outpatient 
prescription drugs. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve AJOVY 225 mg/1.5 ml 
syringe.  
 
Benefits for AJOVY 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial upper denture (D5213). 
 
You asked the Plan to pre-approve the dental item. You say that your top partial denture has been deemed non-
repairable. You say that you are in pain. You say that you are not able to talk and eat. You also say that you are 
embarrassed to be without your top teeth. The Plan denied your request. The Plan says 1 partial upper denture 
is covered every 5 plan years. The Plan also says that the frequency limit has been reached. 
 
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 frequency limit of 1 partial upper 
denture every 5 plan years has been reached. The record shows that the Plan paid for a partial upper denture 
that you received on October 25, 2018, less than 5 years ago. Therefore, we decided that the Plan does not have 
to pre-approve a partial upper denture (D5213).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on April 14, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that the claim has not been paid in full or under 
the terms of the contract. The Plan denied your request. The Plan says the enrollee's claim would be covered 
under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until 
the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to 
verify the member's coverage before rendering services and to know proper billing procedures for a Medicare 
Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal.  Therefore, 
we decided that the Plan does not have to pay for the laboratory services provided on April 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on July 31, 2020. 
 
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says 
with limited exceptions, while the enrollee is a member of our plan, the enrollee must use network providers to 
get your medical care and services. The only exceptions are emergencies, urgently needed services when the 
network is not available, out-of-area dialysis services and cases in which the Plan authorizes use of out-of-
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 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 a domiciliary, rest home visit provided on July 31, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. 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 IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on the medical records provided there is no documentation that the enrollee 
requires the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility versus 
continued care in the acute hospital or a long term acute care hospital or a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the endoscopy provided from July 13, 2020 
to July 22, 2020. 
 
You asked the Plan to waive the copayment for the endoscopy. You say that you were under the impression 
that there was a $0 copayment for each of the services. 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 $325 
copayment for outpatient surgery.  
 
You have been asked to pay a $325 copayment for the endoscopy. The endoscopy falls within the ?Outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers? benefit 
category. The record shows the endoscopy is considered a surgical procedure. 
 
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 endoscopy provided from July 13, 2020 to July 22, 
2020.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the level 3 custodial care visits (99336 x 3). We decided that the Plan 
does not have to pay for the brief emotional assessments (96127 x3).  
 
You asked the Plan to pay for the level 3 custodial care visits (99336 x 3). You say that the services provided 
were medically necessary. The Plan says that the benefit for these services have been exhausted. 
 
The Plan follows Medicare rules. The rules say that Medicare plans must make reasonable and diligent efforts 
to gather and forward information to the Independent Review Entity (IRE). The rules also say that screening 
for depression is non-covered when performed more than one time in a 12-month period. 
 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of codes 99336 x3 have been met. The Plan did not give specific denial rationale for these codes. We 
are unable to substantiate the denial and must find in your favor. We also decided that Medicare rules for 
coverage of codes 96127 x2 have not been met. Specifically, the services appear to be screenings for 
depression. The Plan covered one unit of this service. The remaining units are not covered by Medicare or the 
Plan. Therefore, we decided that the Plan has to pay for the level 3 custodial care visits (99336 x 3) and does 
not have to pay for the brief emotional assessments (96127 x3). 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that this was a follow-up visit and 
you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly 
and you are being charged the correct 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 $40 
copayment for each specialist visit.  
 
You had a specialist visit. Follow-up visits are subject to cost-sharing charges. Therefore, you 
are responsible to pay the $40 copayment.  
 
You have been asked to pay a $40 copayment for a specialist visit. A specialist visit falls within the 
physician/practitioner services, including doctor's office visits 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 a specialist visit provided.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic digital breast tomosynthesis (77062) provided 
on September 2, 2020. 
 
You asked the Plan to pay for the diagnostic digital breast tomosynthesis. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 77062 
has a status indicator of I which is not valid for Medicare purposes. 
 
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 CPT code 77062 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT 
code 77062 has a status indicator of I. This means that CPT code 77062 is not valid for Medicare purposes. 
Based on this information, we decided that Medicare rules for coverage of the diagnostic digital breast 
tomosynthesis have not been met. Therefore, we decided that the Plan does not have to pay for the diagnostic 
digital breast tomosynthesis (77062) provided on September 2, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee March 16, 
2020 to April 14, 2020 and billed under code S9342. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says this claim cannot be paid due to the status code indicator assigned to this code. Medicare 
uses another code to report this service. 
 
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 code billing has an invalid status 
code for Medicare claims. Medicare rules for coverage of this service have not been met. Therefore, we 
decided that the Plan does not have to pay for home health services provided to the enrollee March 16, 2020 to 
April 14, 2020 and billed under code S9342.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pharmacogenomic panel (81408, 81401, 81406, 81400, 
81225, 81226, 81227, 81230, 81231, 81232, 81240, 81241, 81256, 81283, 81291, 81328, 81335, 81350, 81355, 
and 81479) provided on July 7, 2020. 
 
You asked the Plan to pay for a pharmacogenomic panel. You say that this was medically necessary. The Plan 
denied your request. The Plan says this was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. If one laboratory procedure evaluates multiple 
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis CPT code. 
 
We find that CPT codes 81408, 81401, 81406, 81400, 81225, 81226, 81227, 81230, 81231, 81232, 81240, 
81241, 81256, 81283, 81291, 81328, 81335, 81350, 81355, and 81479 are not supported in the medical record. 
The services these codes represent should be billed with one unit of service of the appropriate CPT code. Based 
on this information, we decided that Medicare rules for coverage of a pharmacogenomic panel have not been 
met.  
Therefore, we decided that the Plan does not have to pay for a pharmacogenomic panel (81408, 81401, 81406, 
81400, 81225, 81226, 81227, 81230, 81231, 81232, 81240, 81241, 81256, 81283, 81291, 81328, 81335, 81350, 
81355, and 81479) provided on July 7, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. 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 Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found based on the medical records provided daily 
skilled services are not required. This enrollee does not require the services on an inpatient basis, in a skilled 
nursing facility setting. Services in a long-term care facility on a part time basis appear appropriate 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an extra heavy duty hospital bed (E0303RR). 
 
You asked the Plan to pre-approve an extra heavy duty hospital bed. You say that the item is necessary. The 
Plan denied your request. The Plan says the current hospital bed is less than five years old. Therefore, coverage 
criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare pays for the least expensive option of 
repair vs. replacement of durable medical equipment (DME). Replacement due to wear is not covered during 
the reasonable useful lifetime of the equipment.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an extra heavy duty hospital bed have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an extra heavy duty hospital bed (E0303RR).