Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for face mask interface (A7031), portable gaseous oxygen (E0431) and an oxygen concentrator (E1390) provided on February 15, 2020.
You asked the Plan to pay for the DME. You say that you would like reconsideration because you supplied the equipment that was prescribed. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order; therefore, the billed services cannot be verified.
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 physician order and proof of delivery for the supplies provided in this case. 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 for face mask interface (A7031), portable gaseous oxygen (E0431) and an oxygen concentrator (E1390) provided on February 15, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergent ambulance transport provided to the enrollee 
on January 28, 2020. 
 
You asked the Plan to pay for this transport. You say that this claim should be paid.  The Plan denied your 
request. The Plan says the enrollee did not have prior authorization.  
 
Medicare rules say that plans can require enrollees to get prior authorization. The Plan contract says that non 
emergent ambulance transport requires prior authorization. The Plan did not authorize this transport. Therefore, 
we decided that the Plan does not have to pay for non-emergent ambulance transport provided to the enrollee 
on January 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a next-generation sequencing-based tumor mutation panel test provided to the enrollee on March 2, 2020.
You asked the Plan to pay for the testing. You say that this is medically necessary. The Plan denied your request. The Plan says there is no clinical peer-reviewed evidence that this test is medically necessary for this enrollee.
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 pay for the testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has been diagnosed with splenic marginal zone lymphoma. The next-generation sequencing-
based tumor mutation panel was performed during the diagnostic stage of the enrollee's evaluation. The submitted medical records do not document that the enrollee has recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. The requested testing is not medically necessary according to the criteria. 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for a next-generation sequencing-based tumor mutation panel test provided to the enrollee on March 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a fine needle aspiration biopsy (10005) 
performed on April 1, 2020. 
 
You asked the Plan to waive the copayment for a fine needle aspiration biopsy. You say that you should not 
have to pay because you had no copayments for similar procedures in previous years. The Plan denied your 
request. The Plan says the correct copayment was applied. 
 
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 $295 
copayment for Medicare-covered surgery or other services received on an outpatient basis.  
 
You have been asked to pay a $295 copayment for a fine needle aspiration biopsy. A fine needle aspiration 
biopsy when received on an outpatient basis falls within the "Outpatient Surgery and Other Medical 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 (10005) performed on April 1, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on January 7, 
2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 80157: 
 
Carbamepazine; free 
 
CPT 80159: 
 
Clozapine 
 
CPT 80162: 
 
Digoxin; total 
 
CPT 80173: 
 
Haloperidol 
 
CPT 80177: 
 
Levetiracetam 
 
CPT 80201: 
 
Topiramate 
 
HCPCS G0483: 
 
Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and 
distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms 
(any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, 
elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally 
recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in 
signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., 
to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes 
specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed 
 
 
We find that the denied codes are not supported in the medical record. Specifically, there is no valid physician 
order for these services, and the services were done by urine sampling rather than blood sampling. 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 drug testing services provided to the enrollee on January 7, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supplies used during air ambulance transport provided on 
March 15, 2020. 
 
You asked the Plan to pay for the supplies. The Plan denied your request. The Plan says that supplies are 
included in the base ambulance service. 
 
The Plan must follow Medicare rules. Medicare rules say that payment under the fee schedule for ambulance 
services covers both the transport of the beneficiary to the nearest appropriate facility and all items and services 
associated with such transport; and does not include a separate payment for items and services furnished under 
the ambulance benefit. Therefore, we decided that the Plan does not have to pay for the supplies used during air 
ambulance transport provided on March 15, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to waive the copayment for the continuous passive motion (CPM) device 
provided from May 8, 2020 to May 26, 2020. 
 
You asked the Plan to waive the copayment for the CPM. You say that you were unhappy about the service you 
received and will not pay the copay. The Plan denied your request. The Plan says that you pay 20% of the 
total cost for durable medical equipment. 
 
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 has not provided any documentation (ex. EOB) confirming what they 
have paid and what your responsibility is. Without this documentation we are unable to substantiate the Plan's 
decision and what you owe for cost sharing. Therefore, we decided that the Plan has to waive the copayment 
for the continuous passive motion (CPM) device provided from May 8, 2020 to May 26, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services for dialysis care that you provided on January 31, 2020.
You asked the Plan to pay for physician's services for dialysis care. You say that the patient was in dire need of dialysis treatment for his condition and you could not resist treating the patient 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 physician's services for dialysis care that you provided on January 31, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Magnetic Resonance Angiography (MRA) Chest. 
 
You asked the Plan to pre-approve an MRA Chest (71555). You say that the MRA is routine for your 
diagnosis. The Plan denied your request. The Plan says a similar test was previously performed recently and the 
results do not show why you would need another test. 
 
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 an MRA Chest (71555). Our reviewer 
says that the MRA is not medically necessary. Our physician reviewer found based on the records the enrollee 
had an aortic aneurysm repair on January 13, 2020 and is now clinically stable with a recent chest CT on July 
7, 2020 showing no residual abnormalities. In this circumstance, the records do not support the medical 
necessity for additional aortic imaging at this time. Coverage criteria for additional aortic imaging with a chest 
MRI are not met since the results would not be expected to evaluate any area that has not been already 
adequately evaluated with the chest CT angiogram. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRA Chest (71555) have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Magnetic Resonance Angiography (MRA) Chest.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on January 17, 
2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the rendering provider is not participating with the plan. 
 
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 laboratory services provided to the enrollee on 
January 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an osteogenesis (bone growth) stimulator 
device provided on April 20, 2020. 
 
You asked the Plan to waive the coinsurance for osteogenesis stimulator. You say that you were under the 
impression that this item would be cheap or free and are not sure why you have to pay so much. The Plan 
denied your request. The Plan says the coinsurance amount you are being charged is correct. 
 
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 20% 
coinsurance for in-network osteogenesis stimulator. The allowed amount of the claim is $4,520, resulting in a 
coinsurance obligation of $904. 
 
You have been asked to pay 20% coinsurance for osteogenesis stimulator. Osteogenesis stimulator falls within 
the Durable Medical Equipment and Related Supplies 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 
coinsurance for an osteogenesis (bone growth) stimulator device provided on April 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown for tooth 19. 
 
You asked the Plan to pre-approve a crown for tooth 19. 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. 
 
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 a crown for 
tooth 19 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 a crown for tooth 19. Our reviewer says 
that the documentation does not support that the requested crown is medically reasonable or necessary. Our 
physician reviewer found the enrollee's dental record and radiographs indicate that the root canal filling does 
not appear to be within the guidelines of acceptable. There are reasons where the apex cannot be reached but a 
determination should be made to rule out reinfection due to inadequate cleansing of the root canal spaces prior 
to crown placement to insure a good prognosis. Therefore, the enrollee does not meet criteria for the requested 
crown. 
 
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 a crown for tooth 19 have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a crown for tooth 19.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided February 17, 2020 to 
February 24, 2020. 
 
You asked the Plan to pay for the inpatient hospital care. You say that the services were medically necessary. 
The Plan denied your request. The Plan says no itemized statement or bill was included with the original claim. 
 
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 inpatient services are not supported in the record. Specifically, an itemized bill or statement 
was not provided when the original claim was submitted. A corrected claim with the itemized statement or bill 
must be submitted to the health plan. Based on this information, we decided that Medicare rules for coverage of 
the inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for 
inpatient hospital care provided February 17, 2020 to February 24, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve echocardiography.
You asked the Plan to pre-approve echocardiography. 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. 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 echocardiography. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee has paroxysmal atrial fibrillation on anticoagulation and a possible
Patent foramen ovale (PFO) on recent echocardiogram January 23, 2020. In this circumstance of no
documented recurrent Transient Ischemic Attack (TIA) while on anticoagulation and ongoing indication for
anticoagulation in the setting of paroxysmal atrial fibrillation the records do not support the necessity for PFO
closure or for an additional echocardiogram. Results of an additional echocardiogram (PFO or not) would
likely not change treatment in this setting since the enrollee needs to be anticoagulated anyway for
management of atrial fibrillation.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of echocardiography have not been met. Therefore, we decided that the Plan does
not have to pre-approve echocardiography.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says based on the available information, it cannot be determined that the use of this drug is 
reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the enrollee has a 
diagnosis of triple negative breast cancer with metastatic lesions in the bone, lung, and brain. Review of 
documentation does not include the enrollee's status of microsatellite instability or mismatch repair deficient. 
Compendia requires this to meet coverage criteria. Without the support of the documentation, medical 
necessity cannot be determined. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the crown and endodontic therapy for tooth #24. 
 
You asked the Plan to pre-approve the crown and endodontic therapy for tooth #24. The Plan denied your 
request. The Plan says the services are not medically necessary and do not meet the criteria for coverage. 
 
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 crown and 
endodontic therapy for tooth #24 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 crown and endodontic therapy for 
tooth #24. Our reviewer says that the criteria for coverage has not been met. Our physician reviewer found that 
tooth #24 does not appear to have any pathologic condition, does not appear to be missing any tooth structure 
and is not compromised by decay. Our reviewer says that the request for root canal treatment and a crown is 
not supported for tooth #24 as there is no apparent damage to the tooth structure or the nerve. 
 
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 crown and endodontic therapy for tooth #24 have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the crown and endodontic therapy for tooth #24.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endodontic therapy (D3310) for tooth #8. 
 
You asked the Plan to pre-approve endodontic therapy (D3310) for tooth #8. You say that the enrollee has 
periodontitis and the tooth cannot be restored with a filling. The Plan denied your request. The Plan says tooth 
#8 does not meet the criteria for coverage. 
 
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 endodontic 
therapy (D3310) for tooth #8 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 endodontic therapy (D3310) for tooth 
#8. Our reviewer says that the criteria for coverage has not been met. Our physician reviewer found that the 
provided x-rays show there has been a root canal procedure performed on #8 previously. Our reviewer says that 
the requested code is reserved for initial treatment of an anterior tooth, therefore it is not appropriate in this 
case. 
 
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 endodontic therapy (D3310) for tooth #8 have not been met. Therefore, we 
decided that the Plan does not have to pre-approve endodontic therapy (D3310) for tooth #8.