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

 
We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to 
the enrollee on March 25, 2020. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says Comprehensive Genomic Profile (CGP) testing (i.e. Guardant-360? and NEXT-Generation) 
requires use of CPT 81479. 
 
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 various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare 
rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay 
for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on March 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crowns (D6740) for tooth #'s 28 and 30 and a 
pontic (D6245) for tooth #29. 
 
You asked the Plan to pre-approve the retainer crowns and pontic. You say that the bridge for tooth #'s 28, 29, 
and 30 is medically necessary to fill the space of the missing tooth, and prevent the spread of the adjacent teeth. 
The Plan denied your request. The Plan says the documents fail to demonstrate a specific medical condition 
that would preclude the use of a removable partial denture. 
 
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 retainer 
crowns and pontic when the services are medically necessary and reasonable.  
 
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 retainer crowns and pontic. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the provided -rays 
clearly show there is extensive distal decay on tooth #30 that extends to at least the level of the bony crest if not 
beyond.  This tooth would not be considered a viable tooth for an abutment due to the extent of the decay and 
the inability to properly place a crown margin on it, and as such a replacement bridge would not be a viable 
alternative.  Our reviewer found that there has also been no showing of a medical or neurological disorder that 
would preclude the use of a removable appliance, which now may extend to fill the space of #30, which is 
currently non-restorable due to the expansive decay. Our physician reviewer also found that given the provided 
records demonstrating the extensive decay of tooth #30 making the tooth not viable as an abutment, there can 
be no finding of necessity for the requested bridge from #28-30. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the retainer crowns and pontic have not been met. Therefore, we decided that 
the Plan does not have to pre-approve retainer crowns (D6740) for tooth #'s 28 and 30 and a pontic (D6245) for 
tooth #29.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xiidra eye drops. 
 
You asked the Plan to pre-approve the Xiidra. You say that this enrollee has tried many different over the 
counter medications, and none have helped like the Xiidra does. The Plan denied your request. The Plan says 
this drug is not covered for the enrollee's condition by Medicare Part B. 
 
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 Xiidra eye drops.  
 
Benefits for the Xiidra 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the enrollee does 
not require daily inpatient therapy. 
 
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 services. Our physician reviewer 
found that from a nursing perspective, the enrollee received oral medications, and had stable vital signs. There 
are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee is at a contact guard to 
standby assist level with functional mobility. She required varying assist with activities of daily living. 
Although there are identifiable skilled therapy service needs, the enrollee does not require skilled nursing or 
therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria 
for an inpatient basis in a SNF setting. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that the enrollee would benefit from 5 weeks of 
rehab therapy. The Plan denied your request. The Plan says the enrollee does not require daily skilled nursing 
or rehab services. 
 
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 services. Our physician reviewer 
found that from a nursing perspective, the enrollee had stable vital signs, and was treated for pain with effect. 
There are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee is at a maximal 
assist to dependent level for bed mobility and transfers. He required varying assist with activities of daily 
living. Although there are identifiable skilled therapy service needs, the enrollee does not require skilled 
nursing or therapy services on a daily basis. He does not meet severity of illness or intensity of service  criteria 
for an inpatient basis in a SNF setting. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hernia repair surgical assistant services provided on 
December 17, 2019. 
 
You asked the Plan to pay for the surgical assistant services. You say that the Plan should pay this claim. The 
Plan denied your request. The Plan says the claim form indicates the services were performed by a Registered 
Nurse First Assistant. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for the hernia repair surgical assistant 
services provided on December 17, 2019.
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 if you hurt your hip it could result in a ten-hour 
surgery. You say that you need additional care until you can better care for yourself. The Plan denied your 
request. The Plan says care can be provided in another setting. 
 
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 that your nursing, medical and rehabilitation needs do not require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer says that you are you?re 
your prior level of function and could receive services at a lower level of care. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Superion interspinous spacer/Vertiflex device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says until the device's efficacy has been established, this cannot be approved. 
 
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 pre-approve the device. Our reviewer says that the 
requested device is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the Vertiflex device is experimental. More research is needed to show safety and efficacy. There is no 
spinal instability in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Superion interspinous spacer/Vertiflex device.
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 you are requesting IRF level of care. The Plan 
denied your request. The Plan says services can safely be received in other settings. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer 
says that rehab services can be received at a lower level of care. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF services. You say that the enrollee has COVID and cannot stay at the 
assisted living facility. The Plan denied your request. The Plan says the enrollee does not require skilled 
services on a daily basis. 
 
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 services. Our physician reviewer 
found that from a nursing perspective, the enrollee had stable vital signs and her lungs were clear. There are no 
identifiable skilled nursing service needs. The enrollee did not receive or require skilled therapy service needs. 
Skilled therapy or nursing services are not required on a daily basis. She does not meet severity of illness or 
intensity of service criteria for an inpatient basis in a SNF setting. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an out-of-network revascularization 
procedure (C9604) and echocardiography (93306) provided from February 5, 2020 to February 20, 2020. 
 
You asked the Plan to waive the coinsurance for a revascularization procedure and echocardiography. You say 
that you were told that you should not owe anything for these services. The Plan denied your request. The Plan 
says these services processed 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 40% 
coinsurance for out of network radiological diagnostic services and out of network surgical services.  
 
You have been asked to pay a $3671.77 coinsurance for a revascularization procedure and echocardiography 
($9,179.41 allowed amount x 40% = $3671.77). 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 
an out-of-network revascularization procedure (C9604) and echocardiography (93306) provided from February 
5, 2020 to February 20, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from November 07, 
2020 to November 10, 2019 and November 15, 2019 to December 07, 2019. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's 
condition no longer required daily skilled services at an inpatient SNF level of care. 
 
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 pay for the skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse.  
 
 
The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and 
judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled 
therapy on an inpatient basis in a SNF setting. 
 
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 skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from November 07, 2020 to November 10, 
2019 and November 15, 2019 to December 07, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on April 14, 2020. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be reported with one 
unit of CPT 81479 and the appropriate DEX Z-Code.  
 
We looked at the file and Medicare rules. The requested Guardant360 testing was billed with multiple CPT 
codes. Per the applicable article, this testing must be reported with CPT 81479 and the appropriate DEX Z-
Code. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on April 14, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the retreatment of previous root canal therapy (D3347) 
provided on May 18, 2020. 
 
You asked the Plan to pay for the retreatment of previous root canal therapy (D3347). You say that upon your 
visit the staff told you that the dental work would be covered by insurance. You say that you weren't informed 
until after that the dental work was not covered. The Plan denied your request. The Plan says the service is 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
retreatment of previous root canal therapy (D3347) provided on May 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic radiology provided on May 21, 2020. 
 
You asked the Plan to pay for the diagnostic radiology. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require 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 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 diagnostic radiology provided on May 21, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a fine needle aspiration biopsy provided on 
February 19, 2020. 
 
You asked the Plan to waive the copayment for a fine needle aspiration biopsy. You say that this was a biopsy 
not a surgical procedure 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 $390 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
You received a fine needle aspiration biopsy on February 19, 2020. A fine needle aspiration biopsy is 
considered an outpatient surgical procedure. Therefore, you are responsible to pay the $390 copayment.  
 
You have been asked to pay a $390 copayment for a fine needle aspiration biopsy. A fine needle aspiration 
biopsy falls within the outpatient surgery, including services provided at hospital outpatient facilities and 
ambulatory surgical centers 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 fine 
needle aspiration biopsy provided on February 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the aflibercept injection (J0178) provided 
on January 27, 2020. 
 
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to 
the service provided. 
 
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 non-chemotherapy prescription drugs.  
 
You have been asked to pay $378.01($1,890.06 x 20% coinsurance) for the Medicare Part B non-chemotherapy 
drug injection provided. 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 the aflibercept injection (J0178) 
provided on January 27, 2020.