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

 
We decided that the Plan does not have to pre-approve home infusion therapy (S9345). 
 
You asked the Plan to pre-approve home infusion therapy. You say that this should be covered. The Plan 
denied your request. The Plan says this cannot be approved as requested. 
 
The Plan must follow Medicare rules. Medicare rules say that CPT codes with a status code of I are not valid 
for Medicare purposes. 
 
We looked at the file and Medicare rules. The code the service at issue was requested with has a status code of 
I and is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of home infusion therapy have not been met. Therefore, we decided that the Plan does not have to 
pre-approve home infusion therapy (S9345).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbosacral radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that RFA is covered when specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has left-sided sacroiliac 
(SI) joint pain. She has tried physical therapy and medication without improvement. A previous nerve block 
was completed on December 19, 2018 and the response to this treatment is not documented. A repeat block 
showed 85 percent pain reduction. The requested RFA of the lateral sacral branches is considered 
experimental/investigational in nature and is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve lumbosacral radiofrequency ablation (RFA).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 28, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the outpatient services (G0470 and 90832). You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says utilization of 
network providers is required when possible and available. 
 
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 medical services provided on January 28, 2020 
by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for train of four monitoring (95937) provided on December 30, 
2019. 
 
You asked the Plan to pay for the train of four monitoring. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says it is inappropriate to bill the code for 
neuromuscular junction testing for train of four monitoring. 
 
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 95937 is neuromuscular junction testing (repetitive 
stimulation, paired stimuli), each nerve, any 1 method. 
 
We find that CPT code 95937 is not supported in the record. Specifically, train of four monitoring is integral to 
the primary neuromonitoring procedure and not separately reimbursable. Additionally, it is inappropriate to use 
the code for neuromuscular junction testing for train of four monitoring. Based on this information, we decided 
that Medicare rules for coverage of the train of four monitoring have not been met. Therefore, we decided that 
the Plan does not have to pay for train of four monitoring (95937) provided on December 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the treatment of a root canal obstruction (D3331) provided 
on March 30, 2020. 
 
You asked the Plan to pay for the treatment of a root canal obstruction. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says this service is not 
a covered benefit under your contractual policy. 
 
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 service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the treatment of a 
root canal obstruction (D3331) provided on March 30, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 Plasma-Based Comprehensive Genomic 
Profiling testing provided on March 22, 2020 billed with multiple line items of different CPT codes. 
 
You asked the Plan to pay for the Guardant 360 testing as billed. You say that this should not be denied as 
experimental as this is a proven test which is supported for this patient. The Plan denied your request. The Plan 
says on review, it was found that no payment can be made for this testing because the provider is unbundling 
when there is a single CPT code which describes this testing. 
 
The Plan must follow Medicare rules. Medicare rules say that in order to report the Guardant360 testing, one 
unit of code 81479 should be reported with the appropriate DEX Z-code.  
 
As there is a single CPT code which describes this testing, the rule for coverage of this testing as billed have 
not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 Plasma-Based 
Comprehensive Genomic Profiling testing provided on March 22, 2020 billed with multiple line items of 
different CPT codes.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient skilled nursing facility (SNF) 
care provided February 13, 2020 to February 25, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the services provided. 
 
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 per day, for days 1-20 and a $178 copayment per day, for days 21-100, for skilled nursing facility 
care rendered by an in-network provider.  
 
You have been asked to pay a $890 copayment ($178 x 5 days) for skilled nursing facility care rendered by an 
in-network provider. The record shows that you received inpatient skilled nursing care from January 3, 2020 to 
January 16, 2020 and then from February 13, 2020 to February 25, 2020, for a total of 25 days. According to 
the plan contract, enrollees are responsible to pay a $178 copayment for days 21-100. 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 skilled nursing facility (SNF) care provided February 13, 2020 to 
February 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a preventive procedure (D1999). 
 
You asked the Plan to pre-approve the preventive procedure. You say that a Plan representative advised that 
you were entitled to a 50% discount for these services. The Plan denied your request. The Plan says this service 
is not covered under your 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 pre-approve a 
preventive procedure (D1999).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of residual tooth roots (D7250) and an 
extraction (D7210) of tooth #4. 
 
You asked the Plan to pre-approve the removal of residual tooth roots and extraction. The Plan denied your 
request. The Plan says removal of residual tooth roots is not a covered benefit under the enrollee's plan. The 
Plan also says that the documentation does not support that surgical techniques would be necessary for the 
tooth removal. 
 
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 extractions 
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 extraction. Our reviewer says that 
the extraction of tooth #4 is not medically necessary. Our physician reviewer found the documentation does not 
support the need for bone removal, tooth sectioning and/or elevation of a mucoperiosteal flap for the removal 
of tooth #4 (D7210). 
 
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 extraction have not been met. Though the Plan offers a dental benefit in 
excess of Medicare coverage, removal of residual tooth roots (D7250) is not among those covered under this 
benefit. Therefore, we decided that the Plan does not have to pre-approve the removal of residual tooth roots 
(D7250) and an extraction (D7210) of tooth #4.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durolane. 
 
You asked the Plan to pre-approve Durolane. You say that the enrollee has taken pain medication and it isn't 
working. The Plan denied your request. The Plan says step therapy requirements have not been met. 
 
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 Durolane. Our reviewer says that the 
criteria for coverage of Durolane have not been met. Our physician reviewer found the Plan requires a trial of 
Monovisc and Orthovisc before they will approve the requested drug. The record does not show that the 
enrollee has tried these drugs. There is no documentation indicating that the Plan's required drugs would likely 
be less effective or have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Durolane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Durolane.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve comprehensive oral exam (D0150). 
 
You asked the Plan to pre-approve the dental services. You say that you have an authorization to go to that 
provider and you are not sure why the services are being denied. The Plan denied your request. The Plan says 
D0150 is not listed as a service under the Oral surgery referral guidelines of the National Provider Reference 
Guide. The plan has approved for a consultation (D9310) for the enrollee to receive the proper services. 
 
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 
comprehensive oral exam (D0150).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on December 17, 2019 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. The Plan says that 
the member's primary care physician did not refer these services. 
 
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 December 17, 2019 by an 
out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on June 25, 2019. 
 
You asked the Plan to pay for drug tests. You say that you have submitted a valid physician laboratory 
requisition form. The Plan denied your request. The Plan says the denial of payment for these services is 
correct, because the documentation submitted does not support a valid order for these tests. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific 
lab services is required for covered lab services.  
 
We looked at the file and Medicare rules. The documentation submitted does not include a valid physician 
order or clear intent to order the specific lab services billed on this claim. Based on this information, we 
decided that Medicare rules for coverage of drug tests have not been met. Therefore, we decided that the Plan 
does not have to pay for drug testing provided on June 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital visit (CPT 99223) provided to the enrollee on 
February 16, 2020. 
 
You asked the Plan to pay for the visit. You say that this should be paid for. The Plan denied your request. The 
Plan says the claim was processed correctly. 
 
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 code 99223 is not supported in the medical record. Specifically, this code was not billed with 
the appropriate primary, first-listed or principal diagnosis. Based on this information, we decided that Medicare 
rules for coverage of the visit have not been met. Therefore, we decided that the Plan does not have to pay for a 
hospital visit (CPT 99223) provided to the enrollee on February 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services (D3330) provided on February 20, 2020. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered. The Plan denied 
your request. The Plan says the dental provider accepts private contract only. 
 
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. Dental services must be received from providers that participate in the 
Medicare program in order to be covered. Therefore, we decided that the Plan does not have to pay for dental 
services (D3330) provided on February 20, 2020.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Doxil (Q2050). 
 
You asked the Plan to pre-approve Doxil. You say that the enrollee has failed other drugs and would be an 
appropriate recipient for Doxil. The Plan denied your request. The Plan says that step therapy criteria have not 
been met. 
 
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 Doxil. Our reviewer says that the use of 
Doxil is supported in this case. Our physician reviewer found the Plan requires a trial of anthracycline based 
therapy before they will approve the requested drug. While there are other types of anthracyclines, the health 
plan's denial is not specific as to which one of these anthracyclines the enrollee must first try. Therefore, the 
request for the anthracycline therapy Doxil meets 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 Doxil have been met. Therefore, we decided that the Plan has to pre-approve 
Doxil (Q2050).  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan has to pre-approve a repeat transthoracic echocardiogram (TTE). 
 
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 medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that TTE is covered when specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee developed recurrent left 
ventricular dysfunction with reduced left ventricular ejection fraction of 30 to 35 percent soon after 
percutaneous mitral valve replacement. A repeat echocardiogram now about eight months post procedure is 
reasonable and appropriate even in the absence of symptoms to assess for return to improved ejection fraction. 
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 a repeat transthoracic echocardiogram (TTE).  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that your needs remain custodial and custodial care is specifically stated as 
non-covered by Medicare. 
 
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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric services. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee was admitted to the 
hospital on July 3, 2020 with unspecified psychosis, bipolar disorder, and obsessive-compulsive disorder. 
Based on the submitted records, it is not expected that she will improve in a reasonable period of time beyond 
the dates in question, as she does not have suicidal or homicidal ideation and denies hallucinations. She is 
compliant with treatment and is not showing any acute threats to safety. It does not appear that active treatment 
is taking place. The continued services are not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued inpatient psychiatric services.