Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested physician's services. 
 
You asked the Plan to pre-approve the physician's services. You say that your endocrinologist informed you 
that the Plan does not have alternative ablation/treatment for thyroid nodules and your only option would be 
surgery. You say your doctor referred you to this physician for possible RFA, which is less drastic of an 
intervention especially since you do not have cancer. The Plan denied your request. The Plan says the provider 
you requested is not part of your primary care physician's network. Also, this physician is not signed up with 
Medicare and does not accept any insurance or Medicare Advantage plan. 
 
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for 
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare 
program. Medicare rules say that no Medicare payment may be made to a beneficiary for items or services 
provided directly by a physician or practitioner who has opted out of the program except in cases involving 
emergencies or urgently needed care. 
 
We looked at the file and Medicare rules. The physician in this case is not a provider or a supplier that is 
enrolled in the Medicare program. This provider has opted out of the Medicare program. Medicare says that no 
provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider 
or supplier is enrolled in the Medicare program. Medicare also says that no Medicare payment may be made to 
a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the 
program except in cases involving emergencies or urgently needed care. Therefore, we decided that the Plan 
does not have to pre-approve the requested physician's services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from April 22, 2020, to 
April 30, 2020. 
 
You asked the Plan to pay for the skilled nursing services. The Plan denied your request. The Plan says the 
enrollee did not require daily skilled services. The Plan also says that vital sign measurement and quarantine 
are not skilled 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 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 April 22, 2020, to April 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the cystoscopy you had on June 5, 2020, 
and the cystoscopy with stent removal you had on June 12, 2020, at an outpatient hospital facility. 
 
You asked the Plan to waive the copayments for the two cystoscopy procedures. You say that it is unfair that 
you have been asked to pay the majority of the cost for the first cystoscopy. You also stated that you shouldn't 
have to pay a copayment for the second cystoscopy because it was repeated because the first one was 
unsuccessful. The Plan denied your request. The Plan says you were charged these copayments 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 $375 
copayment for surgical procedures performed as an outpatient at a hospital.  
 
You have been asked to pay a copayment of $258.85 for the first cystoscopy procedure you had on June 5, 
2020. This is because the allowed amount for this procedure is less than your copayment obligation under the 
terms of your contract. You have also been asked to pay a copayment of $375 copayment for the cystoscopy 
with stent removal you had on June 12, 2020. Regardless of the reason for this second procedure, it was 
separate and distinct from the procedure you had on June 5, 2020. 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 
copayments for the cystoscopy you had on June 5, 2020, and the cystoscopy with stent removal you had on 
June 12, 2020, at an outpatient hospital facility.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on May 12, 
2020. 
 
You asked the Plan to pay for the dental services. You say that you say that the services you received were 
routine. You say that you received your cleaning that you get twice per year. You also say that the dentist used 
the same code that was used in 2019 which was paid. The Plan denied your request. The Plan says periodontal 
maintenance is not 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, periodontal maintenance is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periodontal 
maintenance (D4910) provided on May 12, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy rendered on December 11, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be 
covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The 
Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. 
 
We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare 
and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does 
not have to pay for the home infusion therapy rendered on December 11, 2019.  
 
Benefits for these services 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 pre-approve magnetic resonance imaging (MRI) of the cervical 
spine. 
 
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 the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found that you had a neck fusion surgery in 
June of 2019. A repeat CT scan of the neck spine in April of 2019 noted a mild bulging disc at C3-C4. The 
documentation does not include a detailed physical exam, anticipated plan of care pending MRI results, or 
rationale for a repeat study. Without this supporting documentation, the requested MRI is not reasonable or 
medically necessary. 
 
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 magnetic resonance imaging (MRI) of the cervical spine.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 14, 2020 by a 
non-network provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by a non-network provider without 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 referring provider is not a 
network provider with the Plan. The Plan has network providers available who can provide the items/services 
at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that 
would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay 
for the laboratory services provided on January 14, 2020 by a non-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab testing you received on April 16, 2020. 
 
You asked the Plan to waive the copayment for the lab testing. You say that COVID-19 testing shouldn't have a 
copayment. The Plan denied your request. The Plan says you did not have a COVID-19 test.  Records show 
that you received a Strep Throat screening, not a COVID-19 test.  There is nothing in the records to indicate 
that this testing was related to COVID-19. 
 
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 $7 
copayment for lab tests.  
 
You have been asked to pay a $7 copayment for the lab testing. We looked at the medical records in this case 
and they clearly indicate that you received a Strep Throat Screening test, not a test related to COVID-19. 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 lab testing you received on April 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a Primary Relief V1 device. 
 
You asked the Plan to pre-approve auricular electro-acupuncture device. You say that this is not an electro-
acupuncture device. The Plan denied your request. The Plan says the denial of authorization for this item is 
correct, because this device for stimulation of the ear is not covered for any indication. 
 
The Plan must follow Medicare rules. Medicare rules say that a percutaneous nerve stimulator placed on the ear 
for stimulation is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of auricular electro-acupuncture device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve use of a Primary Relief V1 device.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet injections (64493, 64494). 
 
You asked the Plan to pre-approve facet injections. 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 follows Medicare rules. Medicare rules say that for Diagnostic Facet Joint Injection to be covered 
certain criteria must be met. 
 
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 facet injections. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the coverage criteria was not met and 
therefore, a repeat diagnostic MBB is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet injections (64493, 64494).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a shoulder-hand-wrist orthosis (L3960) provided to the
enrollee on February 24, 2020.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your
request. The Plan says the documentation does not indicate services are necessary for treatment of the
enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a shoulder-hand-wrist
orthosis (L3960) provided to the enrollee on February 24, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiation therapy. 
 
You asked the Plan to pre-approve radiation therapy. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not 
been met. 
 
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 radiation therapy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found in summary, proton therapy is not experimental, but rather is simply another means 
of delivering radiation, and has been in use for the treatment of oncology patients for decades. There are 
dosimetric advantages to using proton therapy over intensity-modulated radiation therapy (IMRT) in select 
situations, in which proton therapy offers a clinically meaningful benefit. For this enrollee with T2N0 anal 
cancer, proton therapy would not plausibly be more beneficial to this enrollee than standard therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiation therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve radiation therapy.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transportation services provided on April 30, 2020. 
 
You asked the Plan to pay for the transportation services. You say that you did not request this service to come 
to the hospital. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided 
that the Plan does not have to pay for the transportation services provided on April 30, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered by the out of network 
(OON) provider on February 6, 2020. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without 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 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 laboratory services rendered by the out of network (OON) provider on February 6, 
2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided on 
May 17, 2020. 
 
You asked the Plan to pay for genetic testing. You say that the enrollee's treating physician ordered this testing 
to determine if there was a more effective therapy to treat the enrollee's condition. The Plan denied your 
request. The Plan says the denial of payment for this testing is correct, because this testing was not billed with 
the appropriate coding. 
 
The Plan must follow Medicare rules. Medicare rules say that CGP testing must be billed with CPT code 81479 
for date of service May 17, 2020.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for 
comprehensive genomic profile (CGP) testing provided on May 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable control system and adapter plate. 
 
You asked the Plan to pre-approve the requested items. The Plan denied your request. The Plan says the 
enrollee's upper limb strength and function are adequate for the enrollee to control the power options using 
their own switches. 
 
The Plan follows Medicare rules. Medicare rules say that wheelchair options and accessories are only covered 
under certain medical indications. 
 
The documentation shows that an expandable control system was requested. 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 requested items. Our physician reviewer found that the enrollee is 
independent in feeding, and simple meal prep. She has 3+ strength in her upper extremity on the left. The 
documentation does not reveal that the enrollee requires other types of proportional or non-proportional input 
devices. She does not need to operate 3 or more powered seating actuators through the drive control, or an 
attendant control. Her strength and ability to perform meal prep and self-feed indicate she would have to ability 
to control any power options on the wheelchair through their own individual switches. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-
approve an expandable control system.  
 
The documentation shows that an adapter plate for the back was requested. We looked at the file and the rules. 
The rules say that there is no separate payment for mounting hardware for a seat or back cushion. Based on this 
information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an adapter plate.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered by the out of network 
(OON) provider on February 4, 2020. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without 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 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 laboratory services rendered by the out of network (OON) provider on February 4, 
2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 panel rendered on May 8, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure 
code 81479. 
 
The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. 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 pay for the Guardant360 panel rendered on May 8, 2020.