Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the prophylaxis and comprehensive oral evaluation 
provided on May 19, 2020. 
 
You asked the Plan to pay more for the prophylaxis and comprehensive oral evaluation. You say that you 
needed a plaque cleaning and this office could take you as a new patient. You say that you wouldn't have 
incurred out-of-network costs if your dentist office was not closed The Plan denied your request. The Plan says 
the claim processed correctly. 
 
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 claim processed correctly. The Plan 
is only obligated to pay the allowed amount for a prophylaxis from an out-of-network provider. You are 
responsible for any amount greater than the payment made by the Plan. You also had a comprehensive oral 
evaluation on April 23, 2019, which exhausted your benefit. Therefore, we decided that the Plan does not have 
to pay more for the prophylaxis and comprehensive oral evaluation provided on May 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the external infusion pump. 
 
You asked the Plan to pre-approve the external infusion pump. You say that you would like reconsideration 
because this pump is medically necessary. The Plan denied your request. The Plan says the member will be 
receiving Rocephin which does not require an external infusion pump. 
 
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 external infusion pump. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the information states that the enrollee will be receiving Rocephin that does 
not require an external infusion pump to safely deliver the medication. 
 
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 external infusion pump have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the external infusion pump.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic activities, direct (one on one) patient contact by 
the provider (use of dynamic activities to improve functional performance), each 15 minutes (97530) provided 
May 21, 2020. 
 
You asked the Plan to pay for therapeutic activities. You say that the notes as dictated by the doctor are fully 
supportive of the physical therapy. These services were provided in good faith that the Plan would reimburse 
appropriately as per your contract. The Plan denied your request. The Plan says the records do not support the 
service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that the documentation submitted do not support the total time required for the billed service. The 
appropriate unit has been processed.  Of note, the total treatment time spent was 45 minutes, minimum 53 
minutes are required to support the billed services. It is noted that multiple attempts were made to contact the 
provider for additional information without success. Based on this information, we decided that Medicare rules 
for coverage of therapeutic activities have not been met. Therefore, we decided that the Plan does not have to 
pay for therapeutic activities, direct (one on one) patient contact by the provider (use of dynamic activities to 
improve functional performance), each 15 minutes (97530) provided May 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to make additional payment for the dental extractions (D7210), 
alveoloplasty (D7310), and placement of biological dressing to reduce bleeding (D9999) provided on June 18, 
2020. 
 
You asked the Plan to make additional payment for the rendered dental services. You say that you believe that 
this should be paid in full since your heart condition makes these services medically necessary. The Plan 
denied your request. The Plan says these are dental services that are not covered by Medicare. The only 
services covered under your dental plan are the extractions themselves which were paid leaving you with 50% 
coinsurance. 
 
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 dental 
extractions with 50% coinsurance. 
 
You have been asked to pay 50% coinsurance for the dental extractions. Alveoloplasty and placement of 
biological dressing to control bleeding are not listed as covered services under your dental plan. Although you 
may have required these services due to a medical condition, these treatments are dental by definition and are 
excluded from coverage under Medicare. Therefore, we decided that the Plan does not have to make additional 
payment for the dental extractions (D7210), alveoloplasty (D7310), and placement of biological dressing to 
reduce bleeding (D9999) provided on June 18, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) services 
provided from February 20, 2020, to February 29, 2020. 
 
You asked the Plan to waive the copayment for the SNF services. You say that this service was necessary and 
was approved, so it should be paid in full. The Plan denied your request. The Plan says you were charged this 
copayment 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 $0 
copayment for days 1-20 and a $128 copayment per day for days 21-100 for skilled nursing facility services. In 
addition, a new benefit period will begin when you have been discharged from a skilled care in a skilled 
nursing facility for 60 consecutive days. 
 
Records show that you were in a SNF from December 11, 2019, to December 31, 2020, for a total of 21 days.  
You were then readmitted to this SNF on February 20, 2020.  Because February 20, 2020 is less than 60 days 
after your first discharge on December 31, 2019, these two SNF stays are part of the same benefit period.  
Because you had already exhausted the copayment-free portion of your SNF benefit during the stay in 
December, you have appropriately been charged a $128 copayment per day for the stay you had from February 
20, 2020, to February 29, 2020. This period is a total of 10 days, so your total copayment obligation for this 
stay is $1280. 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 skilled nursing facility (SNF) services 
provided from February 20, 2020, to February 29, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on June 2, 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 drug testing services provided on June 2, 2020.
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 December 13, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are 
available in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan 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 December 13, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Afirma Assay. 
 
You asked the Plan to pre-approve Afirma Assay. You say that you would like reconsideration as this service 
will help to prevent surgery. The Plan denied your request. The Plan says the member does not meet Medicare 
coverage criteria for this service. 
 
The Plan follows Medicare rules. Medicare rules say that MolDX will reimburse Afirma services for patients 
with specific conditions. 
 
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 Afirma Assay. Our reviewer says that 
the member does not meet Medicare coverage indications for the Afirma Assay. Our physician reviewer found 
the records do not indicate that ht member has one or more thyroid nodules with a history or characteristics 
suggesting malignancy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Afirma Assay have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Afirma Assay.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that you can safely receive the services you need 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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute rehab hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, at an intensive rehabilitation therapy 
program. You continue to have a need for skilled therapy with ongoing safety concerns and a potential for 
functional improvement, however, the documentation doesnt support that you would meet criteria for 
admission to an acute inpatient rehabilitation facility. There is no indication that you would require skilled 
rehabilitation in an IRF, participating in rehab services 15 hours a week, under the supervision of a physician 
with at least 3 visits weekly to regain or maintain your functional status. Our physician reviewer found that 
your condition does not meet Medicare criteria for IRF 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vascepa 1mg capsules. 
 
You asked the Plan to pre-approve Vascepa. You say that the medication is medically necessary. The Plan 
denied your request. The Plan says this medication is not eligible for coverage under the Part B medical 
benefit. 
 
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 Vascepa 1mg capsules.  
 
Benefits for Vascepa 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says a review of the current medical literature indicates that this service is considered 
experimental and investigational. 
 
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 in this circumstance therapy change based on data obtained from a CardioMEMs device has been 
demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy.  
Moreover, concerns have been raised about potential bias in this trial calling into question the results.  
Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and 
not recommended in current guidelines for the treatment of heart failure.  Medicare coverage criteria are not 
met since the device should still be considered experimental or investigational. 
 
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 CardioMEMS device for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forGuardant360 molecular pathology genomic profiling provided to the enrollee on May 22, 2020.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The PlansaysMedicare requires use of CPT 81479 to report a Guardant360 molecular pathology genomic profiling for bladder cancer.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 services have not been met.Therefore, we decided that the Plandoes not haveto pay forGuardant360 molecular pathology genomic profiling provided to the enrollee on May 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe knee orthosis, the addition to lower extremity, and the addition to lower extremity orthosis provided on April 5, 2020.You asked the Plan to pay forthe knee orthosis, the addition to lower extremity, and the addition to lower extremity orthosis. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not supported by the documentation.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid proof of delivery for the supplies provided in this case. Review of the file shows that the documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies or a proof of delivery for the billed date of service. The submitted invoice indicates that the item was shipping on March 30, 2020 and delivered on April 1, 2020, however, the billed date of service is April 5, 2020. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay forthe knee orthosis, the addition to lower extremity, and the addition to lower extremity orthosis provided on April 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interrogation device evaluation (93295 and 93296) 
provided on May 18, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for interrogation device evaluation. You say that the services rendered were 
medically necessary. The Plan denied your request. The Plan says prior authorization must be obtained for non-
emergent services rendered by an out-of-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 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 interrogation device evaluation (93295 and 
93296) provided on May 18, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup (D2950) and post and core services 
(D2954). 
 
You asked the Plan to pre-approve the core buildup and the post and core services. You say that the enrollee is 
having extreme pain. You say that the requested services were approved in the past, but that the enrollee was 
unable to get the treatment completed. The Plan denied your request. The Plan says the codes which remain in 
dispute are not listed as covered benefits. 
 
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 pre-approve core 
buildup (D2950) and post and core services (D2954).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia services (00630) provided on March 20, 2020. 
 
You asked the Plan to pay for anesthesia services. You say that this was billed correctly. The Plan denied your 
request. The Plan says that anesthesia services provided by a CRNA (Certified Registered Nurse Anesthetist) 
are to be billed with the appropriate modifier. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan?s denial states that anesthesia services provided by a CRNA must be 
billed with a modifier; however, the record shows that the rendering provider for the service at issue is an MD. 
Therefore, we decided that the Plan has to pay for anesthesia services (00630) provided on March 20, 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 pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted to the acute hospital setting on October 30, 2020 for 
Covid19 associated respiratory failure. The enrollee had a history of mitral infective endocarditis's diagnosed in 
September 14, 2020. The enrollee was finishing a 6-8 week course of Vanc and Gentamicin. The 
documentation does not support that the enrollee requires services at the LTACH that are not available at the 
acute care hospital where the enrollee is currently receiving care. There are no services available at the LTACH 
that the enrollee requires that are not available at the health care setting being offered by the health plan. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.