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

 
We decided that the Plan does not have to pre-approve a custom upper arm prosthesis for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this item is not a covered benefit. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found at this time the requested robotic orthosis is not proven to be more beneficial for treatment of the 
enrollee's medical condition/function of hemiparesis after stroke than any available standard therapy. The 
requested device is not reasonable and necessary for the diagnosis or treatment of an illness or injury or  to 
improve the functioning of a malformed body member. The literature does not reveal sufficient evidence that 
this device improved functional quality of life in patients that have hemiparesis post stroke. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a custom upper arm prosthesis for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 molecular pathology services provided on 
March 2, 2020. 
 
You asked the Plan to pay for the Guardant360 molecular pathology services. You say that you would like the 
plan to reconsider their denial. 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 Guardant360 molecular pathology services are not supported in the medical record. 
Specifically, CPT code 81479 should be used to report Gurdant360 molecular pathology services along with 
the appropriate DEX Z-code identifier must be entered adjacent to the CPT code in the comment/narrative 
field. Based on this information, we decided that Medicare rules for coverage of the Guardant360 molecular 
pathology services have not been met. Therefore, we decided that the Plan does not have to pay for the 
Guardant360 molecular pathology services provided on March 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6549 that 
were issued on January 21, 2020 to January 30, 2020. 
 
You asked the Plan to pay for the compression stockings. You say that you did not realize these would not be 
covered and feel that you should not have to pay this bill. The Plan denied your request. The Plan says these 
stockings are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression 
stockings identified with code A6549 that were issued on January 21, 2020 to January 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for panoramic x-rays (D0330) provided August 26, 2019. 
 
You asked the Plan to pay for the dental services. You say that the provider had contacted the plan before you 
had work done. You would like this claim The Plan denied your request. The Plan says this service exceeds the 
benefit frequency limitation. 
 
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. This service is limited to once 
every 3 years. The records show this service was last provided August 7, 2017. 
 
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 pay for 
panoramic x-rays (D0330) provided August 26, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab work provided on January 14, 2020 by an out of network 
(OON) provider. 
 
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and approved for 
payment. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 lab work provided on January 14, 2020 by an out 
of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
You asked the Plan to cover Dronabinol. The Plan did not grant this request. We received this case to 
conduct an independent review.  
 
We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request 
for Dronabinol. The drug is requested to treat anorexia, protein calorie malnutrition and cachexia, which 
are off-label (non-FDA approved) uses. The Medicare-approved compendia do not contain any citations to 
support the use of the requested drug, as prescribed, for treatment of the noted conditions. Therefore, the 
requested drug is not being prescribed for a medically accepted indication as defined by Medicare law. As 
such, an exceptions request based on medical necessity cannot be considered because the requested drug, as 
prescribed, does not meet the definition of a Medicare Part D drug. Therefore, the requested drug is not 
eligible for coverage under Medicare Part D for the noted conditions. 
 
For coverage under Part D, Medicare requires that the drug must be prescribed for a medically accepted 
indication. A medically accepted indication means a use that is approved by the FDA or a use that is 
supported by one or more citations in Medicare approved compendia.  
 
Our Physician Reviewer reviewed this file and determined that there are no citations in the Medicare 
approved compendia that support the use of Dronabinol for the diagnosed conditions. As a result, the drug 
is not being prescribed for a medically accepted indication as defined by Medicare law. As such, it cannot 
be covered under the Medicare Part D benefit for these conditions. An exceptions request based on medical 
necessity cannot be considered because this drug, as prescribed, does not meet the definition of a Medicare 
Part D drug. Therefore, our decision is that the Plan is not required to provide coverage for Dronabinol.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the laboratory work provided on March 
20, 2020. 
 
You asked the Plan to waive the coinsurance for the laboratory work. You say that the claim was billed 
incorrectly. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% of 
the cost for in-network Medicare-covered laboratory services.  
 
You have been asked to pay $1.60 which is 20% of the allowed amount for the laboratory work. The allowed 
amount is $8.00. ($8.00 x 20% = $1.60). The laboratory work falls within the ?Outpatient diagnostic tests and 
therapeutic services and 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 the laboratory work provided on March 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visits (99202), a lumbar sacral radiologic examination 
(72100), electrical stimulation (G0283), mechanical traction (97012) and unattended electrical stimulation 
(97014) provided on February 20, 2020 through March 12, 2020. 
 
You asked the Plan to pay for the chiropractic services. You say that you would like reconsideration because 
these services have been helpful you and believed they would be covered. The Plan denied your request. The 
Plan says the services received are explicitly excluded; therefore, the services are not covered by the plan as an 
additional benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for office visits (99202), a lumbar sacral radiologic examination (72100), 
electrical stimulation (G0283), mechanical traction (97012) and unattended electrical stimulation (97014) 
provided on February 20, 2020 through March 12, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded 80307 and G0480 provided on 
September 26, 2019. 
 
You asked the Plan to pay for the drug testing. 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 80307 and G0480 are not supported in the medical record. Specifically, the 
documentation submitted did not include a valid physician order/lab requisition or medical records stating 
exactly what tests were to be performed. Based on this information, we decided that Medicare rules for 
coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for 
the drug testing coded 80307 and G0480 provided on September 26, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on 
January 3, 2020 and January 6, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were billed a total 
of 8 days between two hospital stays. You say you should only be charged for a 5-day stay. The Plan denied 
your request. The Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $375 
copayment for each day for days 1 to 5 for in-network Medicare-covered hospital care. 
 
You have been asked to pay a $375 copayment for each day of the inpatient hospital stay. ($375 x 3 days = 
$1,125). The inpatient hospital stay falls within the Inpatient Hospital Care benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for the inpatient hospital stay provided on January 3, 2020 and January 
6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve knee surgery (27447) to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve OON knee surgery. You say that you have had previous surgery at the 
requested facility and feel the requested facility has better outcomes. The Plan denied your request. The Plan 
says the services at issue 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
knee surgery (27447) to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodic oral exam (D0120) bitewing x-rays (D0277)
cleaning (D1110) intraoral-periapical first x-ray (D0220) crown tooth 19 (D2740) provided February 19, 2019
to March 5, 2019.
You asked the Plan to pay for the dental services. You say that you never received an EOB for the procedure.
The previous calendar year you submitted a bill from the same dentist and was reimbursed. You assumed you
could do the same but the claim was denied. The Plan denied your request. The Plan says for covered dental
services enrollee's must receive their dental services from an in-network provider.
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 pay for periodic
oral exam (D0120) bitewing x-rays (D0277) cleaning (D1110) intraoral-periapical first x-ray (D0220) crown
tooth 19 (D2740) provided February 19, 2019 to March 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the upper partial denture reline on March 16, 2020. 
 
You asked the Plan to pay for the upper partial denture reline. You say that you are on a fixed income and 
cannot pay the bill. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
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 pay for the upper 
partial denture reline on March 16, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit on February 15, 
2020. 
 
You asked the Plan to waive the copayment for the emergency room visit.. You say that the copayment should 
be waived. 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 $90 
copayment for Emergency Care.  
 
You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls 
within the Emergency Care 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 an 
emergency room visit on February 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) and four 
additional intraoral periapical x-rays (D0230 x4) provided on February 20, 2020. 
 
You asked the Plan to pay for the first intraoral periapical x-ray and additional intraoral periapical x-rays. You 
say that a Plan representative advised you that this provider was in-network with your dental plan. The Plan 
denied your request. The Plan says these services are not covered by the Plan. The Plan also says that you did 
not elect to purchase an optional supplemental benefit plan. 
 
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 pay for the first 
intraoral periapical x-ray (D0220) and four additional intraoral periapical x-rays (D0230 x4) provided on 
February 20, 2020.  
 
Your complaint about being given false information by the Plan is not a valid appeal for medical coverage. 
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to 
make a decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from January 28, 2020 
through January 31, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The 
Plan denied your request. The Plan says that the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the review has determined that the record showed that at the time of inpatient admission the 
admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency 
department (ED) and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from January 28, 2020 through January 31, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vascular embolization rendered on September 4, 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 procedure code 37242 is not supported. 
 
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 code 37242 is arterial embolization for acquired arterial 
malformation using imaging guidance with radiological supervision and interpretation, and intraprocedural 
roadmapping. 
 
We find that CPT code 37242 is not supported in the medical record. Specifically, the operative report does not 
contain documentation of a vascular embolization or arterial occlusion with imaging guidance. 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 vascular embolization rendered on September 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on January 13, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The 
Plan says that the rendering facility is also out-of-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 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 physician services provided on January 13, 2020 
by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the three retainer crowns, pontic, core buildup, and 
extraction provided on January 7, 2019. 
 
You asked the Plan to pay for the retainer crowns, pontic, core buildup, and extraction. You say that these 
services should be covered under your medical plan because you fell and broke your tooth. You also say that 
the Plan should cover injuries to your mouth. The Plan denied your request. The Plan says your plan does not 
cover these services, because they are excluded from coverage. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the three retainer crowns, pontic, 
core buildup, and extraction provided on January 7, 2019.