Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hot or cold packs therapy rendered from March 4, 2020, 
to March 25, 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 procedure code 97010 is not separately payable. 
 
The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is 
always bundled into payment for other services not specified.  
 
We looked at the file and Medicare rules. The provider billed code 97010. This code has a status indicator of B 
and is not separately payable. Therefore, we decided that the Plan does not have to pay for the hot or cold packs 
therapy rendered from March 4, 2020, to March 25, 2020.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets criteria for IRF care. The Plan 
denied your request. The Plan says that members needs could possibly be met a lower level care. 
 
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 the patient's nursing, medical and rehabilitation needs do not require an acute rehab hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. The patient does not require treatment 
by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. There is not a reasonable expectation that this patient will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Our 
physician reviewer found that the enrollee's 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 for the enrollee.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory testing provided on May 2, 2020. 
 
You asked the Plan to pay for lab tests. You say that you are appealing. The Plan denied your request. The Plan 
says that the denial of payment for these services is correct, because this testing is not covered for screening 
purposes. 
 
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 enrollee was referred for lab tests by an in-network provider. The order made by the in-network provider 
clearly states that this testing was not being ordered for screening purposes, and that the results were needed for 
diagnosis and management of the enrollee's condition. The file does not show that the plan provided notice that 
lab tests would not be covered. Under Medicare rules, this means lab tests is considered approved by the plan. 
Therefore, we decided that the Plan has to pay for laboratory testing provided on May 2, 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 Synvisc-One for the enrollee. 
 
You asked the Plan to pre-approve Synvisc-One. You say that this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says that the enrollee does not meet step therapy criteria. 
 
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 Synvisc-One. Our reviewer says that 
Synvisc-One is not medically reasonable and necessary for the enrollee. There is no indication that the enrollee 
has tried and failed Orthovisc and Monovisc or that they would likely be less effective and/or likely have 
adverse effects for the patient. Our physician reviewer found that the enrollee's condition does not meet step 
therapy criteria for Synvisc-One. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc-One for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve psychotherapy (90837) with an out-of-network 
provider. 
 
You asked the Plan to pre-approve psychotherapy. You say that you have seen this provider for years and feel 
comfortable with them. The Plan denied your request. The Plan says outpatient behavioral health services are 
available with providers who are in network. 
 
The Plan must follow Medicare rules. Medicare rules say that certain provider types are not eligible for 
Medicare coverage.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy have not been met. Specifically, the requested provider is a Licensed Mental Health 
Counselor. This provider type is not eligible for Medicare coverage of mental health services. Therefore, we 
decided that the Plan does not have to pre-approve psychotherapy (90837) with an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse the full amount for the cone beam CT (D0367) provided 
on May 27, 2020. 
 
You asked the Plan to reimburse the full amount for the cone beam CT. You say that you were experiencing 
pain in a previously capped tooth. You say that your dentist referred you to another dentist that was properly 
equipped to perform the service. You say that since you have Medicare and Medicaid 100% of your bill should 
be covered. The Plan denied your request. The Plan says cone beam CT is not listed as a covered service. The 
Plan also says that any services not listed are not covered. 
 
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. The Evidence of Coverage clearly states that any services not listed are 
not covered. Therefore, we decided that the Plan does not have to reimburse the full amount for the cone beam 
CT (D0367) provided on May 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the comprehensive oral evaluation (D0150) 
provided on May 19, 2020. 
 
You asked the Plan to reimburse you for the dental service. You say that your regular dentist was closed for 
your scheduled appointment in April. You say they could not get you in until July or August. You say that if 
your regular dentist was open, you would not have had to go out of network. You also say that the service 
should be covered because the national news and advertisements advised you would not be charged deductibles 
and copays. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 
years. The Plan says the frequency limit has been exceeded. 
 
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 and the comprehensive oral evaluation 
is a covered service, the frequency limit of once every 3 years has been exceeded. The record shows that you 
received this service on April 22, 2019, thus exhausting the benefit. Therefore, we decided that the Plan does 
not have to reimburse you for the comprehensive oral evaluation (D0150) provided on May 19, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Insertion of interlaminar/interspinous process 
stabilization/distraction device. 
 
You asked the Plan to pre-approve Insertion of interlaminar/interspinous process stabilization/distraction 
device. 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 Insertion of interlaminar/interspinous 
process stabilization/distraction device. 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 low back pain. 
The requested spacer device remains experimental. More research is needed to show safety and efficacy. 
Therefore, the enrollee does not meet criteria for the requested 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 Insertion of interlaminar/interspinous process stabilization/distraction device 
have not been met. Therefore, we decided that the Plan does not have to pre-approve Insertion of 
interlaminar/interspinous process stabilization/distraction device.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency care services provided on October 11, 2019. 
 
You asked the Plan to pay for emergency care. You say that this claim is the Plan's responsibility. The Plan 
denied your request. The Plan says the denial of payment for these services is correct, because the enrollee was 
enrolled in a hospice program for this date of service and therefore the Plan is not responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for emergency care services provided on October 11, 2019.
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 this should be covered. The Plan denied your 
request. The Plan says you could be treated at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found from a nursing perspective, you require oral 
medications and insulin. Your vital signs are stable. Regarding rehabilitation services, you received physical 
therapy in the acute hospital and were at a minimal assist level with bed mobility and transfers. You do not 
meet severity of illness or intensity of service criteria for 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for molecular genetic hereditary predictive screening testing 
provided on March 4, 2020. 
 
You asked the Plan to pay for genetic testing. You say that according to Medicare these diagnosis codes are 
valid. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because 
these tests are not a Medicare benefit for the diagnoses listed and were performed for screening purposes.  

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
There is no documentation in the record of a concern for a specific drug metabolism issue for which this testing 
was ordered. This was provided in the absence of signs/symptoms of a medical condition. This means it is 
screening in nature which is not covered by Medicare.  Therefore, we decided that the Plan does not have to 
pay for molecular genetic hereditary predictive screening testing provided on March 4, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 80157, 80177, 80201, 80162, 
80159, and 80173 provided on December 31, 2019. 
 
You asked the Plan to pay for the laboratory services. 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. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 80157, 80177, 80201, 80162, 80159, and 80173 are not supported in the medical 
record. Specifically, the specimen type collected is incorrect for the billed codes. These tests are performed on 
a blood specimen collected by venipuncture. However, the submitted toxicology request form indicates the 
specimen was urine. Based on this information, we decided that Medicare rules for coverage of the laboratory 
services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
coded 80157, 80177, 80201, 80162, 80159, and 80173 provided on December 31, 2019.
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 May 7, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
approved in advance. 
 
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 May 7, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 panel rendered on May 21, 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 billed incorrectly. 
 
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 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network 
provider on December 20, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says out-of-network 
services are not covered. 
 
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 you by an out-of-network provider on 
December 20, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing rendered on May 23, 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 billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
genetic testing rendered on May 23, 2020.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Erbitux. 
 
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 that the services are not medically 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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee has unresectable disease and 
meets the criteria for coverage of Erbitux. Although Erbitux is not FDA-approved for the treatment of 
metastatic squamous cell carcinoma of the skin, it is supported by major compendia for off-label use for this 
indication. The services are reasonable and 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 been met. Therefore, we decided that the Plan has to pre-
approve Erbitux.  
 
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 lab services provided on March 7, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
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 requested CPT codes are not supported in the medical record. Specifically, the records show 
that the testing was performed with blood sampling, which is collected by venipuncture. However, the lab 
requisition says that a urine specimen was collected. The billed codes cannot be verified. Based on this 
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for the lab services provided on March 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductibles applied to skilled nursing facility (SNF) 
services you received from December 20, 2019, to January 8, 2020. 
 
You asked the Plan to waive the deductibles applied to the SNF services. You say that you were originally 
billed $804.01 for this stay, but your most recent bill has gone up to $1606.25.  You asked for assistance with 
this bill. The Plan denied your request. The Plan says you were assessed these deductibles appropriately. 
 
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 for both 2019 and 
2020, you have a $1,000 annual deductible. 
 
Records show that you were in the SNF from December 20, 2019, to January 8, 2020.  In 2019, you had a 
$1,000 annual deductible.  When you went into the SNF, you still had $804.01 remaining until you hit your 
deductible (i.e., you had only paid $195.99 towards your deductible in 2019 prior to this SNF stay.) That is 
why you were appropriately charged $804.01 for the SNF services from December 20, 2019, to December 31, 
2019.  You then remained in the SNF from January 1, 2020, to January 8, 2020.  You have an annual 
deductible of $1,000 that applies to 2020 services as well.  At the time the claim was processed for the SNF 
services you received from January 1, 2020, to January 8, 2020, you had only paid $197.76 towards your 2020 
annual deductible.  That is why you were appropriately charged the remaining $802.24 for the SNF services 
you received in order to fulfill your deductible obligations for 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 deductibles applied to skilled nursing facility (SNF) services you received 
from December 20, 2019, to January 8, 2020.