Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral for lymphatic massage with an opt-out 
provider. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says lymphatic massage is eligible for coverage when received from providers who have not 
opted out of Medicare and prior approved by the plan. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Medicare 
does not provide coverage for providers who have opted out of Medicare. Therefore, we decided that the Plan 
does not have to pre-approve a referral for lymphatic massage with an opt-out provider.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Palonosetron. 
 
You asked the Plan to pre-approve Palonosetron. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says that the requested drug 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 Palonosetron. Our reviewer says that 
the documentation supports that the requested drug is medically reasonable and necessary. Our physician 
reviewer found the enrollee has right breast cancer. The requested drug is FDA-approved for moderate 
emetogenic risk and cyclophosphamide at planned dose of 600 mg/m2. The documentation supports that the 
requested drug is safe and effective and otherwise reasonable and necessary for this enrollee. Therefore, the 
enrollee meets criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Palonosetron have been met. Therefore, we decided that the Plan has to pre-
approve Palonosetron.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on February 3, 2020, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. 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. 
 
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 laboratory services provided on February 3, 
2020, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a 
participating ambulatory center. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that this copayment should be 
waived. The Plan denied your request. The Plan says the correct copayment has been 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 a $100 
copayment for outpatient surgery/in-network/ambulatory surgical center.  
 
You have been asked to pay a $100 copayment for an outpatient surgery. An outpatient surgery falls within the 
outpatient surgery/in-network/ambulatory surgical center 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 an outpatient surgery provided by a participating ambulatory center.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for echocardiography, transesophageal, real-time with image 
documentation (2D) (with or without M-mode recording); including probe placement, image acquisition, 
interpretation and report (CPT Code 93312) provided on June 9, 2020. 
 
You asked the Plan to pay for the services. You say that the services were necessary. The Plan denied your 
request. The Plan says the provider notes that the TEE was cancelled since the risks outweigh the benefits due 
to a broad base vegetation on the MV.  The procedure was not done and remains non-covered. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. This cannot be paid because it was 
not billed as a discontinued procedure with modifier -73. Therefore, we decided that the Plan does not have to 
pay for echocardiography, transesophageal, real-time with image documentation (2D) (with or without M-
mode recording); including probe placement, image acquisition, interpretation and report (CPT Code 93312) 
provided on June 9, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided to the enrollee on July 9, 
2019. 
 
You asked the Plan to pay for the ambulance services. You say that this claim was filed timely. The Plan 
denied your request. The Plan says that the claim was not filed timely and denied correctly. 
 
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 ambulance services was not filed until July 20, 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 ambulance services provided to the enrollee on July 9, 2019.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the medical services (CPT code 36821-LT) provided on June 12, 2020. 
 
You asked the Plan to pay for CPT code 36821. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not substantiated their reasoning for denial. The case file provided 
by the Plan does not show that CPT code 36821 cannot be paid with modifier LT in a place of service setting of 
11 per Medicare criteria. Therefore, we decided that the Plan has to pay for the medical services (CPT code 
36821-LT) provided on June 12, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray rendered on July 16, 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 procedure code 71045 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 71045 and 32555. Code 71045 is a column II code with a 
modifier indicator of 1 when billed with column I code 32555. Code 71045 was not billed with an appropriate 
modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the chest 
x-ray rendered on July 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on June 6, 2020, by an OON 
provider. 
 
You asked the Plan to pay for a hospital outpatient clinic visit or for a pneumococcal vaccine and its 
administration. You say that you are requesting authorization for services rendered. The Plan denied your 
request. The Plan says rules for payment have not been met. 
 
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 6, 2020, by 
an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglass frames (V2020) and anti-reflective lens coating 
(V2750) provided on July 23, 2020. 
 
You asked the Plan to pay for eye glass frames and anti-reflective lens coating. You say that the items should 
be covered. The Plan denied your request. The Plan says you have exhausted the maximum allowed for this 
benefit. 
 
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 provides a $100 allowance once every 24 months for you to use towards the purchase price 
of eyewear. If the eyewear you purchase costs more than $100, you are responsible for the difference. 
 
We looked at the file and the Plan's rules. You have exhausted you $100 allowance towards eyewear and are 
responsible for the difference. Based on this information, we decided that the Plan's rules for coverage of eye 
glass frames and anti-reflective lens coating have not been met. Therefore, we decided that the Plan does not 
have to pay for eyeglass frames (V2020) and anti-reflective lens coating (V2750) provided on July 23, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for train of four testing provided on June 8, 2020. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the cost is 
included in the cost of the primary procedure. 
 
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 train of four testing is integral to accomplishing the approved neuromonitoring services. Based 
on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that 
the Plan does not have to pay for train of four testing provided on June 8, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided on 
May 14, 2020 by the appealing provider. 
 
You asked the Plan to pay for the CGP testing. You say that the services were provided and payment should be 
rendered. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
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 comprehensive genetic testing panel provided is considered to be screening in nature as it was performed 
in the absence of specific signs or symptoms of a condition. There is no documentation from the ordering 
physician which indicates a specific concern for which this testing is needed to diagnose or treatment a medical 
issue. As such, this is a screening service that is not covered by Medicare. Therefore, we decided that the Plan 
 
 
does not have to pay for comprehensive genomic profile (CGP) testing provided on May 14, 2020 by the 
appealing provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for low osmolar contrast material (Q9966) provided on May 19, 
2020. 
 
You asked the Plan to pay for low osmolar contrast material. You say that the enrollee had multiple exams on 
this date. The Plan denied your request. The Plan says the supported unit was previously billed and paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that an additional unit of CPT code Q9966 are not supported in the medical record. The medical record 
only supports one unit of CPT code Q9966, which was previously billed and paid. Based on this information, 
we decided that Medicare rules for coverage of low osmolar contrast material have not been met. Therefore, we 
decided that the Plan does not have to pay for low osmolar contrast material (Q9966) provided on May 19, 
2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiovascular risk assessment panel provided to the enrollee 
on April 29, 2020. 
 
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 cardiovascular risk assessment panels are not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. Medicare does not cover cardiovascular risk 
assessment panels. This claim cannot be paid as submitted as these services are not covered by Medicare. 
Therefore, we decided that the Plan does not have to pay for cardiovascular risk assessment panel provided to 
the enrollee on April 29, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the breast magnetic resonance imaging (MRI) provided on 
July 8, 2020. 
 
You asked the Plan to pay for the MRI. You say that the Plan should pay this claim. The Plan denied your 
request. The Plan says the MRI was done for screening purposes. 

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 test at issue in this appeal, the MRI, is being 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 
breast magnetic resonance imaging (MRI) provided on July 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a high frequency chest oscillation device (E0483) provided 
to the enrollee on May 11, 2020. 
 
You asked the Plan to pay for the device. You say that the claim should be paid. The Plan denied your request. 
The Plan says there is no valid physician order. 
 
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 physician order in the records to support medical necessity for the supplies 
provided in this case. 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 a high frequency 
chest oscillation device (E0483) provided to the enrollee on May 11, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injection, vedolizumab, 1 mg (J3380) 
provided on February 21, 2020, and April 17, 2020. 
 
You asked the Plan to waive the coinsurance for injection, vedolizumab, 1 mg. You say that the service should 
be covered. The Plan denied your request. The Plan says the cost share was 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a 20% coinsurance for injection, vedolizumab, 1 mg. This service falls within the 
Medicare Part B prescription drugs 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 coinsurance for 
injection, vedolizumab, 1 mg (J3380) provided on February 21, 2020, and April 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 2 core build up (D2950) and a filling (D2391) for tooth 
# 17. 
 
You asked the Plan to pre-approve the core build up and filling. You say that teeth # 4 and 12 have multiple 
fractures that need full coverage restorations. You say that the enrollee is in pain. You say that these services 
would improve the enrollee's quality of life and prevent premature tooth loss due to fracture extension. The 
Plan denied your request. The Plan says core build up is not listed as a covered service. The Plan says that 1 
filling per tooth, per 36 months is covered. The Plan also says that the frequency limit for this service 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 core build up is not among those 
covered under this benefit. Additionally, the frequency limit of 1 filling per tooth, per 36 months, has been 
reached. The record shows there is a paid claim for a filling for tooth # 17 on October 14, 2020. Therefore, we 
decided that the Plan does not have to pre-approve 2 core build up (D2950) and a filling (D2391) for tooth # 17.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the digital diagnostic mammography 
provided on July 22, 2020. 
 
You asked the Plan to waive the copayment for the diagnostic mammography. You say that this was your 
yearly mammogram so there should not be a copayment. 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 $85 
copayment for Medicare covered diagnostic radiological services.  
 
You have been asked to pay a $85 copayment for the diagnostic mammography. The diagnostic mammography 
falls within the Medicare covered diagnostic radiological services benefit category. The record shows this was 
a diagnostic mammography not a screening mammography. 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 digital diagnostic mammography provided on July 22, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee arthrotomy rendered on June 13, 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 procedure code 27310 was billed with an inappropriate modifier. 
 
The Plan must follow Medicare rules. The rules say that modifier -79 reports an unrelated procedure by the 
same physician during a postoperative period. 
 
We looked at the file and Medicare rules. The provider billed procedure code 27310 with modifier -79. There is 
no original procedure reported during a post-operative period to support the use of the -79 modifier. Therefore, 
we decided that the Plan does not have to pay for the knee arthrotomy rendered on June 13, 2020.
Appeal type: Surgery
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 22, 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 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 June 22, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a CT scan provided on February 13, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for a CT scan. 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 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 a CT scan provided on February 13, 2020 by an 
out of network (OON) provider.