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

 
We decided that the Plan does not have to waive the copayment for the lesion removal services you received at 
an outpatient hospital facility. 
 
You asked the Plan to waive the copayment for the lesion removal services. You say that you had no idea that 
removing these lesions would be considered a surgical service. You say this charge is unfair. The Plan denied 
your request. The Plan says you were charged this amount correctly.  The Plan says that because the allowed 
amount for this procedure is less than your copayment obligation, you are responsible for the full amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 
copayment for surgery services at an outpatient hospital facility.  
 
You have been asked to pay a $325 copayment for the lesion removal services. Lesion removal is considered a 
surgical service, so the lesion removal services fall within the surgery services at an outpatient hospital facility 
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 the lesion removal services you 
received at an outpatient hospital facility.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Superion Spinal Distraction Device at Level 4-5 of 
Lumbar Spine for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that the implantation of the device is most 
appropriate treatment due to the patient's radiating low back pain. The Plan denied your request. The Plan says 
that experimental and investigational procedures are excluded from coverage. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The spacer device is 
experimental. More research is needed to show safety and efficacy. Our physician reviewer found that the 
enrollee's condition does not meet criteria for coverage of these services. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Superion Spinal Distraction Device at Level 4-5 of Lumbar Spine for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on July 24, 2020, to July 27, 
2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for chiropractic services. 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 these services were self-referred. 
 
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 chiropractic services provided on July 24, 2020, to 
July 27, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve c-tub (receptacle to sterilize and disinfect instruments). 
 
You asked the Plan to pre-approve the item. You say that the item is necessary. The Plan denied your request. 
The Plan says this is not covered because it is not used to treat a medical condition. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve c-tub (receptacle to sterilize and disinfect instruments).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the full amount for the periodontal scaling and root 
planing (D4341) for all 4 quadrants. 
 
You asked the Plan to pre-approve the full amount for the dental services. You say that you would like the Plan 
to pay 100% for these services. You say that you need these services as a result of cancer treatment. You say 
that you cannot afford to pay for these services. You also say that if you do not get these services done, you 
will lose your teeth. The Plan denied your request. The Plan says scaling and root planing is listed as a covered 
service. The Plan says that there is a 50% coinsurance for scaling and root planing. 
 
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, there is 50% coinsurance for scaling 
and root planing. This is a contractual obligation you agreed to when you enrolled in the Plan's dental 
coverage. Additionally, the provider in this case is not a network provider. The Evidence of Coverage clearly 
states that you may still be billed by an out of network provider for any amount greater than the MAC payment 
made by the plan to the provider. Therefore, we decided that the Plan does not have to pre-approve the full 
amount for the periodontal scaling and root planing (D4341) for all 4 quadrants.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you do not require skilled nursing or skilled 
therapy services on a daily basis. You do not require the necessary services on an inpatient basis, in a skilled 
nursing facility 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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on March 19, 
2020 and billed under codes 95939, 95938, 95861, 95868, 95927 and 95937. 
 
You asked the Plan to pay for services rendered to the enrollee. You say that this claim should be paid. The 
Plan denied your request. The Plan says parts of this claim cannot be paid based on incorrectly reported Place 
of Service (POS) codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, this claim cannot be paid as billed due 
to issues with incorrect POS codes. Medicare billing criteria are not met.  Therefore, we decided that the Plan 
does not have to pay for physician services provided to the enrollee on March 19, 2020 and billed under codes 
95939, 95938, 95861, 95868, 95927 and 95937.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrolle. 
 
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 the claims are being submitted with inappropriate home health data to process and pay 
claims.  
 
 
The Plan says that the Final claim with the correct HHRG code is required to process and pay claims. The 
HHRG code on the claims indicates there were Non-Routine Supplies (NRS) provided, but are not submitted 
on the claim and submitted HIPPS code is invalid as per sheet; 
therefore, per the Medicare guidelines the plan is upholding the claim denials as the provider did not bill with 
an appropriate home health data. The Plan states a corrected claim would be reviewed if submitted.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, the claim cannot be paid as billed due to 
an error with the HIPPS code. Medicare rules for coverage of this service have not been met. Therefore, we 
decided that the Plan does not have to pay for home health services provided to the enrollee.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab services provided on May 12, 2020. 
 
You asked the Plan to pay for the lab services. You say that you took the tests at the direction of your doctor. 
The Plan denied your request. The Plan says that the services are not payable by Medicare. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
The file shows that the services were provided by a contract provider. The file does not show that the Plan 
provided notice that the lab services would not be covered. Under Medicare rules, this means the lab services is 
considered approved by the Plan. Therefore, we decided that the Plan has to pay for the lab services provided 
on May 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya (J3245). 
 
You asked the Plan to pre-approve Ilumya (J3245). You say that you want the enrollee treated with this drug. 
The Plan denied your request. The Plan says the enrollee has not first tried and had a contraindication or 
intolerance to Remicade or Inflectra and Stelara 
 
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 Ilumya (J3245). Our reviewer says that 
the drug is not medically necessary. Our physician reviewer found the enrollee has not trialed Remicade, 
Inflectra or Stelara. Step therapy, as outlined by the plan, requires trial of Remicade or Inflectra and Stelara. 
The documentation does not outline contraindications or reason these medication was not considered. Without 
the support of the documentation, Ilumya is not approved as step criteria is not met. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ilumya (J3245) have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Ilumya (J3245).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lynparza for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says that this is not covered under 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 Lynparza for the enrollee.  
 
Benefits for this drug 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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab services provided on June 1, 2020. 
 
You asked the Plan to pay for the lab services. You say that *** The Plan denied your request. The Plan says 
that the services are not payable by Medicare. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the lab services by a contract provider. The file does not show that the Plan provided 
notice that the lab services would not be covered. Under Medicare rules, this means the lab services is 
considered approved by the Plan. Therefore, we decided that the Plan has to pay for the lab services provided 
on June 1, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient services provided on June 7, 2020. 
 
You asked the Plan to pay for the inpatient services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that the claim submitted for 
payment did not include a correct discharge status and condition code combination for claim reconsideration. 
The Plan will accept a corrected claim for payment reconsideration. Therefore, we decided that the Plan does 
not have to pay for the inpatient services provided on June 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Dexcom G6 Sensor. 
 
You asked the Plan to pay for the Dexcom G6 Sensor. You say that you would like reconsideration because 
you have used the preferred brand of glucose monitor and it does not stick to your skin. The Plan denied your 
request. The Plan says your provider will not submit clinical information because they do not agree with the 
appeal. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Dexcom G6 Sensor have not been met. Specifically, your provider did not elect to send 
medical records because they do not believe that coverage criteria have been met. The documentation that has 
been submitted does not indicate that you meet any of the criteria for coverage of the requested glucose 
monitor. Therefore, we decided that the Plan does not have to pay for the Dexcom G6 Sensor.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the physical therapy to be provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve the physical therapy. You say that this should be a continuity of care. The 
Plan denied your request. The Plan says there are in-network providers that can render the 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 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 physical therapy to be provided by an out-of-network provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a Positron Emission Tomography (PET) scan (78815). 
 
You asked the Plan to pre-approve the PET scan. You say that the PET scan is medically necessary. The Plan 
denied your request. The Plan says that coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
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 PET scan. Our reviewer says that 
the PET scan is medically necessary. Our physician reviewer found the enrollee has Stage III Merkel cell 
Cancer. The requested PET scan meets NCCN guidelines. 
 
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 PET scan have been met. Therefore, we decided that the Plan has to pre-
approve a Positron Emission Tomography (PET) scan (78815).  
 
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 the drug test (80349) provided on July 14, 2020. 
 
You asked the Plan to pay for the drug test. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the submitted CPT code is not payable under OPPS. 
 
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 80349 is not supported in the record. Specifically, per Medicare, CPT code 80349 is not 
valid for payment under OPPS. Based on this information, we decided that Medicare rules for coverage of the 
drug test have not been met. Therefore, we decided that the Plan does not have to pay for the drug test (80349) 
provided on July 14, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee from April 21, 
2020 to April 30, 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 it is not billed with appropriate HIPPS code. A corrected claim can be submitted to the 
claims address on the back of the member's id card with a valid HIPPS code can be billed for claim to 
reconsideration. The Plan states this claim cannot be reprocessed for payment until a corrected claim is 
received. 
 
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, this claim cannot be paid because it 
lacks the correct HIPPS code. The Plan states a corrected claim would be reviewed. Medicare rules for 
coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for home 
health services provided to the enrollee from April 21, 2020 to April 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ophthalmology care with a tertiary level of care provider. 
 
You asked the Plan to pre-approve specialist services. You say that you are requesting continuity with the 
doctors who know about your condition and have the expertise/experience to deal with the disease. The Plan 
denied your request. The Plan says the denial of authorization for these services is correct, because you can be 
treated by a non-tertiary level provider. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollee's needs.
 
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 specialist services. Our reviewer says 
that you do not meet the Medicare criteria for continued care at the tertiary level of care. Our physician 
reviewer found the Plan's denial is medically justified on the basis that it is offering adequate care to meet your 
medical needs through referral to non-tertiary level of care providers. There is nothing unique about your 
condition that would make it medically necessary for you to see the requested tertiary level of care provider.  
 
There is no documentation that you are currently receiving any active treatment and/or medical management of 
your condition that makes it medically necessary for you to continue care with the requested tertiary level of 
care provider. The Plan has shown that they have non-tertiary providers who meet the standards of care 
required for treatment of your condition, and your care can be safely transitioned to a non-tertiary specialist at 
this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of specialist services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve ophthalmology care with a tertiary level of care provider.