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

 
We decided that the Plan does not have to pay for lab work provided 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 paid. The Plan 
denied your request. The Plan says prior authorization was not obtained. The Plan says that the ordering 
physician is 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 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 frames provided on September 3, 2020. 
 
You asked the Plan to pay for the frames. You say that you were never told that you had to wait until next year 
for another pair of frames. The Plan denied your request. The Plan says that your maximum benefit has been 
exceeded. 
 
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 one time per year. 
 
We looked at the file and the Plan's rules. The file indicates the Plan already covered frames and lenses on 
January 18, 2020. Based on this information, we decided that the Plan's rules for coverage of the frames have 
not been met. Therefore, we decided that the Plan does not have to pay for the frames provided on September 
3, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ConfirmMDx testing provided on September 3, 2020. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says coverage 
criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that ConfirmMDx is only covered under certain 
medical indications.  
 
We looked at the file and Medicare rules. The records do not indicate the enrollee is being considered for 
repeat biopsy testing. Based on this information, we decided that Medicare rules for coverage of the testing 
services have not been met. Therefore, we decided that the Plan does not have to pay for the ConfirmMDx 
testing provided on September 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve humidifier (CPT Code E0562) and respiratory assist 
device, bi-level pressure capability, with back-up rate feature, used with noninvasive interface, e.g., nasal or 
facial mask (intermittent assist device with CPAP device) (E0471). 
 
You asked the Plan to pre-approve the DME. You say that you stop breathing for a lengthy time in the night 
without a BiPap machine and it can lead to medical problems. You state you tried the CPAP machine but it did 
not work out at home and you have been working on getting BiPap machine for a year now. The Plan denied 
your request. The Plan says the Medicare rules have not been met. 
 
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 DME have not been met. The medical records we received 
show that you have Obstructive Sleep Apnea. The rules state that this device, (A bi-level positive airway 
pressure device with back-up rate) is not appropriate for Obstructive Sleep Apnea. This decision was based on 
Medicare Guidelines, LCD L33718. Therefore, we decided that the Plan does not have to pre-approve 
humidifier (CPT Code E0562) and respiratory assist device, bi-level pressure capability, with back-up rate 
feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with CPAP 
device) (E0471).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation and complete series of 
intraoral x-rays provided on September 16, 2020. 
 
You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. You 
say that you contacted the Plan prior to receiving these services and were told that the x-rays would be fully 
covered. The Plan denied your request. The Plan says benefits for these services have been satisfied and the 
frequency limitations have been exceeded. The Plan also says that no dental benefits were quoted during your 
call to the Plan on February 20, 2020. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, comprehensive oral evaluation is 
limited to one procedure every three years. The Plan contract also says that full mouth or panoramic x-rays are 
limited to one procedure every five years. The record shows that you received a comprehensive oral evaluation 
and a panoramic x-ray on May 6, 2019, and your comprehensive oral evaluation and full mouth or panoramic 
x-rays benefits have been exhausted. Therefore, we decided that the Plan does not have to pay for the 
comprehensive oral evaluation and complete series of intraoral x-rays provided on September 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the handheld low vision aid provided on June 30, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the handheld low vision aid. You say that you need this to make you more 
independent. The Plan denied your request. The Plan says that there is no authorization on file for these 
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 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 handheld low vision aid provided on June 30, 
2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hydromorphone tabs. 
 
You asked the Plan to pre-approve hydromorphone tabs. The Plan denied your request. The Plan says 
hydromorphone tabs fall under Part D coverage. The Plan also says that your 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 hydromorphone tabs.  
 
Benefits for hydromorphone tabs 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee x-ray (73560) provided on September 1, 2020. 
 
You asked the Plan to pay for the knee x-ray. You say that you would like reconsideration because this service 
was performed in the appropriate place of service. The Plan denied your request. The Plan says the member 
was inpatient during this date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. A 
physician/practitioner/supplier furnishing services to a patient who is a registered inpatient, shall, at a 
minimum, report the inpatient hospital POS code 21 irrespective of the setting where the patient actually 
receives the face-to-face encounter. 
 
We find that CPT code 73560 is not supported in the record. Specifically, the record indicates that this member 
was registered inpatient on the billed date of service. It is not appropriate to bill an outpatient place of service 
code when the member is registered inpatient. Based on this information, we decided that Medicare rules for 
coverage of the knee x-ray have not been met. Therefore, we decided that the Plan does not have to pay for the 
knee x-ray (73560) provided on September 1, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xT gene panel testing provided on September 20, 
2019. 
 
You asked the Plan to pay for the Tempus xT gene panel testing. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed 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 Tempus xT gene panel 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 Tempus xT gene panel testing provided on September 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy services provided on June 15, 
2020. 
 
You asked the Plan to pay for the home infusion therapy 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. 
 
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 CPT Code Manual definition of code S9328 is home infusion therapy, implanted pump pain 
management infusion; administrative services, professional pharmacy services, care coordination, and all 
necessary supplies and equipment (drugs and nursing visits coded separately), per diem. 
 
We find that CPT code S9328 is not supported in the medical record. Specifically, this code has a status code 
of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code 
for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for 
coverage of the home infusion therapy services have not been met. Therefore, we decided that the Plan does 
not have to pay for the home infusion therapy services provided on June 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Vertiflex Superion interspinous device procedure (22869) 
performed on October 13, 2020. 
 
You asked the Plan to pay for a Vertiflex Superion interspinous device procedure. You say that this is a 
medically necessary procedure recognized according to professional standards. The Plan denied your request. 
The Plan says the requested service is not medically necessary or medically supported. 
 
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 a Vertiflex Superion interspinous device 
procedure. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that the spacer device is experimental. More research is 
needed to show safety and efficacy. Furthermore, the device is not medically needed. There is no documented 
spinal instability. 
 
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 Vertiflex Superion interspinous device procedure have not been met. 
Therefore, we decided that the Plan does not have to pay for a Vertiflex Superion interspinous device 
procedure (22869) performed on October 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on October 16, 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 paid. The Plan 
denied your request. The Plan says prior authorization was not obtained. The Plan says that the ordering 
physician 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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for lab work provided on October 16, 2020, by an out-
of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gum surgery to expose more tooth, crown Tooth 4 and 
14 (D4249 x2). 
 
You asked the Plan to pre-approve the dental services. You say that you are requesting review of denial of 
services. The Plan denied your request. The Plan says the service is included in another 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. 
 
Your dentist asked for a service that is included with the crown. Your dentist does not need to send a separate 
request for this service. Therefore, we decided that the Plan does not have to pre-approve gum surgery to 
expose more tooth, crown Tooth 4 and 14 (D4249 x2).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on September 1, 2020 by an 
out of network provider. 
 
You asked the Plan to pay for the physician services. You say that the physician should be paid for the services. 
The Plan denied your request. The Plan says you did not request 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 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 physician services provided on September 1, 2020 by an out of 
network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services (85025, 86738, 87804) provided on March 
16, 2020. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the services were not authorized or emergent. There were network providers 
available. 
 
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 lab services (85025, 86738, 87804) provided on March 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where he/she is currently receiving care. All medically necessary care is being provided in the 
current acute care setting. There are not services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The health plan has approved ongoing care 
in the current acute care setting. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the preventive procedure, comprehensive oral evaluation, 
and complete series of intraoral x-rays provided on September 30, 2020. 
 
You asked the Plan to pay for the preventive procedure, comprehensive oral evaluation, and complete series of 
intraoral x-rays. You say that you would like some assistance paying for these services. The Plan denied your 
request. The Plan says the preventive procedure is not a covered benefit. The Plan also says that your benefits 
for the comprehensive oral evaluation and complete series of intraoral x-rays have been satisfied and the 
frequency limitations have been exceeded. 
 
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, unspecified preventive procedure is not 
among those covered under this benefit. The contract says that comprehensive oral evaluation is limited to one 
procedure every three years. The Plan contract also says that full mouth or panoramic x-rays are limited to one 
procedure every five years. The record shows that you received a comprehensive oral evaluation and complete 
series of intraoral x-rays on March 20, 2019, and your comprehensive oral evaluation, and full mouth or 
panoramic x-rays benefits have been exhausted. Therefore, we decided that the Plan does not have to pay for 
the preventive procedure, comprehensive oral evaluation, and complete series of intraoral x-rays provided on 
September 30, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room care (99283) received 
October 12, 2020. 
 
You asked the Plan to waive the copayment for emergency room care. You say that the laboratory sent you to 
the emergency room, though everything was fine. The Plan denied your request. The Plan says the services 
were provided and therefore, the emergency room copayment applies. 
 
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 emergency care.  
 
You have been asked to pay a $100 copayment for emergency room care. The services at issue fall within the 
emergency care 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 emergency room care 
(99283) received October 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Computed tomography (CT) scan provided on September 
3, 2020. 
 
You asked the Plan to pay for the CT scan. 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 CPT code 74177 is not supported in the medical record. Specifically, this claim was billed with 
place of service 22 (outpatient); however, the documentation shows that the enrollee was inpatient during this 
date of service. Based on this information, we decided that Medicare rules for coverage of the CT scan have not 
been met. Therefore, we decided that the Plan does not have to pay for the Computed tomography (CT) scan 
provided on September 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services provided on July 10, 2020 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for the outpatient hospital 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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the outpatient hospital services provided on July 
10, 2020 by an out of network (OON) provider.