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

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
October 21, 2019. 
 
 
 
You asked the Plan to pay for home health services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says this claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the 
submitted claim does not include the required Q code or appropriate revenue code. Therefore, we decided that 
the Plan does not have to pay for the home health services provided to the enrollee from October 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2750) for tooth # 18. 
 
You asked the Plan to pre-approve the dental service. You say that you had a cavity on your tooth. You say that 
your previous dentist did not fix the cavity before the crown was put on. You say that you were in pain. You 
say that you will need a new crown for this tooth once the cavity gets fixed. You also say that you would like to 
go to a different dentist as the previous one did not do a good job. The Plan denied your request. The Plan says 
crowns are covered once per tooth, 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 crown per 
tooth, every 5 plan years, has been reached. The record shows that the Plan paid for a crown for tooth # 18 that 
you received on May 14, 2020. Therefore, we decided that the Plan does not have to pre-approve a crown 
(D2750) for tooth # 18.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic casts (D0470) provided on July 8, 2020. 
 
You asked the Plan to pay for the dental service. You say that you were advised that you needed this service in 
order to make dentures that fit you properly. You also say that without this, your denture may not fit properly. 
The Plan denied your request. The Plan says diagnostic casts 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 diagnostic casts are not among 
those covered under this benefit. Additionally, the Evidence of Coverage clearly states that any services not 
listed are not covered. Therefore, we decided that the Plan does not have to pay for the diagnostic casts 
(D0470) provided on July 8, 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. The Plan denied your request. The Plan says you do not have 
acute issues which need daily supervision from a rehab physician. 
 
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 physician reviewer found 
that you are living in a private home with a caregiver. You have ongoing problems with ambulation after hip 
replacement after a fall about 2 months ago. Your medical problems are stable. The complexity of your 
nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. The medical record supports a need for physical and 
occupational therapy, but it does not support a need for an intensive rehabilitation therapy program. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 11, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.  
 
We looked at the file and Medicare rules. The documentation shows that the services in question were billed 
with POS code 81. However, the records indicate that the specimen was collected in an office setting, which 
would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. 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 the lab services provided on March 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve epidural injection. You say that you are appealing with records. The Plan 
denied your request. The Plan says the denial of authorization for this service is correct, because this provider 
is out-of-network with the Plan and the enrollee can be treated by an in-network provider. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the medical services to be 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 intravenous infusion, for therapy, prophylaxis, or diagnosis 
(specify substance or drug) (96367) provided July 2, 2020. 
 
You asked the Plan to pay for the infusion therapy services. You say that these charges are for chemotherapy 
you received to fight ovarian cancer. You are requesting that the Plan resolve any issues and pay the agreed 
upon charges for these services. The Plan denied your request. The Plan says the services processed correctly 
and the enrollee has no responsibility due on the claim. This service is included in another service provided at 
the same time by the same provider. 
 
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, we have confirmed that code the 
infusion therapy services has a bundled relationship with code 36591 and cannot be paid as billed. This code 
cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been 
met. Therefore, we decided that the Plan does not have to pay for intravenous infusion, for therapy, 
prophylaxis, or diagnosis (specify substance or drug) (96367) provided July 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on June 2, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for practitioner visit. You say that the enrollee has no choice in the medical 
professionals they are seen by while in the facility. The Plan denied your request. The Plan says the denial of 
payment for this service is correct, because this provider is out-of-network with the Plan and authorization was 
not obtained. 
 
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 2, 2020 by 
an out of network (OON) provider.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Prolia. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says that the step therapy requirement is not met. 
 
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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee has a history of osteoporosis. 
She tried and failed oral bisphosphonate therapy with Alendronate and has received Reclast in 2018 and 2019. 
The Plan requires a trial of Zoledronic Acid before approving the requested drug. In this case, the enrollee has 
tried and failed the required drug. The requested Prolia is medically necessary and reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-
approve Prolia.  
 
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: Favorable

 
We decided that the Plan has to pre-approve CT scan of the chest 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there are no signs of symptoms noted, and no evidence of a recent chest x-ray. 
 
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 scan. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee had a neuroendocrine tumor small bowel resected in 2017.  Surveillance CT scans 
of chest, abdomen and pelvis are medically necessary to monitor for local, regional and distant metastases. As 
such in addition to the already approved CT of the abdomen and pelvis the CT of the chest should be approved 
as medically necessary due to risk of metastatic disease to the chest. 
 
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 scan have been met. Therefore, we decided that the Plan has to pre-approve 
CT scan of the chest  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a duplex scan provided on June 17, 2020. 
 
You asked the Plan to pay for duplex scan. You say that the provider felt it was medically necessary to perform 
this test. The Plan denied your request. The Plan says the denial of payment for this service is correct, because 
this test is not a Medicare benefit for the diagnosis listed and was performed 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, duplex scan, 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 a 
duplex scan provided on June 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided 
on September 10, 2019. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that you have exhausted the dental benefit for 
this service. 
 
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.  
 
We looked at the file and the Plan rules. Based on this information, we decided that the Plan's rules for 
coverage of this service have not been met. Specifically, your request for payment of this service exceeds the 
allowable dental benefit. Oral exams are covered by the Plan once every six months. The Plan previously 
issued payment for a comprehensive oral evaluation provided on May 16, 2019. This service was provided less 
than six months prior to the date of service in question. Therefore, we decided that the Plan does not have to 
pay for the comprehensive periodontal evaluation (D0180) provided on September 10, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve extractions (D7210 x2) and crowns (D7240 x2). 
 
You asked the Plan to pre-approve the extractions and crowns. You say that these services are medically 
necessary. The Plan denied your request. The Plan says the benefit for extractions has been exhausted and the 
crowns are not a covered 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 crowns are not among 
those covered under this benefit. The plan allows for up to two extractions per calendar year. An extraction was 
performed on November 23, 2020. The two requested extractions would exceed the limitation of this benefit. 
Therefore, we decided that the Plan does not have to pre-approve extractions (D7210 x2) and crowns (D7240 
x2).
Appeal type: Lab
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 April 2, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says out-of-network 
services are not covered. 
 
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 April 2, 2020.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve the sleep study. 
 
You asked the Plan to pre-approve the sleep study. You say that you would like reconsideration because this 
service is medically necessary. The Plan denied your request. The Plan says that repeat testing is not supported 
without results of the prior testing that show a clear reason for it. 
 
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 sleep study. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no need for an additional diagnostic Polysomnography because the previous 
Polysomnography, a split-night study, confirmed a diagnosis of severe OSA.  The PAP titration was 
unsuccessful because of the emergence of central events.  Thus it is appropriate to perform a full-night titration 
study with BiPAP. 
 
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 sleep study have been met. Therefore, we decided that the Plan has to pre-
approve the sleep study.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Procedure 81545, oncology thyroid, gene expression of 142 
genes, utilizing fine needle aspirate, provided to the enrollee on April 27, 2020. 
 
You asked the Plan to pay for this service. You say that this service was medically necessary for the enrollee 
and should be covered by the Plan. The Plan denied your request. The Plan says the request is for code 81545 
(oncology, thyroid, gene expression analysis of 142 genes). The request was previously denied stating: The use 
of this test is managed by a Medicare article (Article A54356). These are Medicare rules which direct how this 
test can be used. The rules say that this test can be approved for a person with one or more thyroid nodules who 
has both of the following: One, a fine needle aspiration (FNA) with uncertain results. This is when cells are 
taken from a thyroid nodule to look for signs of cancer. Two, one or more risk factors show the person has a 
higher risk for thyroid cancer. These include a thyroid nodule that is growing, a family history of thyroid 
cancer, hoarseness and/or problems breathing or swallowing, exposure to radiation, a nodule that feels hard 
when compared to the rest of the thyroid, and/or lymph nodes in the neck that are swollen. The records we 
received do not show that both of these are present. The two thyroid nodules were biopsied. The records show 
the enrollee did not meet both criteria for approval. The result of one thyroid nodule biopsy was uncertain but 
there was no documentation of a second risk factor. There was no mention of a growing sized nodule, family 
history of thyroid cancer, no history of radiation exposure, nor was there documentation of abnormal physical 
findings such ad hardness to palpation, or palpable neck nodes. No history of hoarseness or problems with 
breathing or swallowing. This test did not meet medical necessity criteria. As such, MCG Health Ambulatory 
Care 24th Edition Thyroid Nodule Gene Expression Testing ACG: A-0711 (AC); and Local Coverage Article: 
Billing and Coding: MolDX: Afirma Assay by Veracyte (A54356) CMS National Coverage Policy criteria 
have not been met. Therefore, the request for the coverage of 81545 (oncology, thyroid, gene expression 
analysis of 142 genes) for the diagnosis of E04.2 (nontoxic multinodular goiter) is not considered medically 
necessary. 
 
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 records provided do not show 
the enrollee met the Medicare guidelines for this service at the time the service was rendered. Medicare rules 
for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for 
Procedure 81545, oncology thyroid, gene expression of 142 genes, utilizing fine needle aspirate, provided to 
the enrollee on April 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve push bars, a backpack, and a transport accessory 
(K0108, K0108, A9270) for a wheelchair. 
 
You asked the Plan to pre-approve the wheelchair accessories. You say that these accessories are medically 
necessary. The Plan denied your request. The Plan says these items are not primarily medical in nature and the 
transport accessory is for use outside the home and is non-covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home. The rules also state that equipment must be primarily medical in nature. 
 
The transport option at issue in this appeal is for use outside of the home. Although this item may be helpful, 
neither Medicare nor the Plan covers equipment for use outside the home. The requested backpack and push 
bars are not considered medical items and are non-covered. Therefore, we decided that the Plan does not have 
to pre-approve push bars, a backpack, and a transport accessory (K0108, K0108, A9270) for a wheelchair.