Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (80307, G0483) provided on July 1, 
2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the service provided was medically 
necessary. The Plan denied your request. The Plan says prior authorization was not obtained by the facility or 
the provider; therefore, payment has been correctly denied. 
 
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 laboratory services (80307, G0483) provided 
on July 1, 2020, by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve queen size orthopedic mattress. 
 
You asked the Plan to pre-approve the mattress. You say that you have pain in your back and you have 
arthritis. You can't sleep on your current mattress and wakes up with pain all over your body. You would like a 
regular queen size mattress. The Plan denied your request. The Plan says neither Medicare or the Plan covers 
furniture items such as standard or orthopedic mattresses. Medicare covers mattresses only for a hospital bed 
where the hospital bed is medically necessary. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve queen size orthopedic mattress.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (99233) provided on June 15, 2020. 
 
You asked the Plan to pay for the subsequent hospital care. You say that you would like reconsideration 
because these services were medically necessary and denied in error. The Plan denied your request. The Plan 
says CPT code 99233 was reported with another evaluation and management code which was billed on the 
same day by a provider with the same specialty. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say that physicians in the same 
group practice who are in the same specialty must bill and be paid as though they were a single physician. 
 
We find that CPT code 99233 is not supported in the record. Specifically, the record indicates that CPT code 
99233 was billed on the same date of service by a provider in the same group with the same specialty. Based on 
this information, we decided that Medicare rules for coverage of the subsequent hospital care have not been 
met. Therefore, we decided that the Plan does not have to pay for subsequent hospital care (99233) provided on 
June 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the root canal for a molar tooth (D3330) for tooth # 30 
provided. 
 
You asked the Plan to pay for the dental service. You say that your tooth is loose. You say that you need your 
tooth to be repaired. You also say that you have constant pain. The Plan denied your request. The Plan says that 
tooth # 30 is a molar tooth. The Plan also says that root canals are not covered for molar teeth. 
 
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 root 
canal for a molar tooth (D3330) for tooth # 30 provided.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-Melanoma testing provided on March 16, 
2020. 
 
You asked the Plan to pay for the DecisionDx-Melanoma testing. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services provided 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 pay for the DecisionDx-Melanoma testing. Our 
reviewer says that the rendered services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the enrollee a diagnosis of Malignant melanoma of the right forearm. The 
melanoma was treated with wide excision and sentinel node, with no residual melanoma identified. A PET/CT 
scan was negative, indicating that the melanoma is not metastatic. Genetic testing of primary cutaneous 
melanomas (before or following SLN biopsy) is not recommended outside of a clinical study. There is no 
strong evidence that genetic evaluation is medically reasonable and necessary for the management of cutaneous 
melanoma. 
 
 
 
 
Review of the file shows that the plan uses Local Coverage Determination, LCD L38016 to support their 
denial. However, LCD L38016 is not valid for the provider?s headquarters state of Texas. Therefore, we cannot 
use LCD L38016 to substantiate our decision. 
 
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 DecisionDx-Melanoma testing have not been met. Therefore, we decided 
that the Plan does not have to pay for the DecisionDx-Melanoma testing provided on March 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0651) provided to the 
enrollee on July 14, 2020. 
 
You asked the Plan to pay for the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no failure of conservative therapy. 
 
The Plan must follow Medicare rules. Medicare rules say that a PCD is covered when there is documentation of 
a four week trial of conservative therapy.  
 
We looked at the file, and Medicare rules. There is no evidence of any conservative therapy over a four week 
period. Based on this information, we decided that Medicare rules for coverage of the device have not been 
met. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0651) 
provided to the enrollee on July 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for implantable and wearable cardiac device evaluation (93296) 
provided on June 29, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the cardiac services. You say that please see attached medical records. Please 
review and reconsider claim for payment based on medical necessity. The Plan denied your request. The Plan 
says enrollee's must receive their medical services from an in-network provider with the exception being 
urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization 
before services being rendered. 
 
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 implantable and wearable cardiac device 
evaluation (93296) provided on June 29, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the physician services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the physician services. You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent 
to seek out-of-network care. The Plan says there are equally qualified in-network specialists available to you 
that can provide the care and treatment you are requesting. 
 
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 
the physician services to be provided by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay foraquatic therapy provided on October 2, 2019.You asked the Plan to pay foraquatic therapy. You say that the enrollee was pre-approved so10 visitswere provided. You say that the claims should be processed for payment.The Plan denied your request. The Plan says the techniques used could have been applied using land based physical therapy. The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.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 aquatic therapy. Our reviewer says that skilled services were not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that there was no documentation in the records that land based physical therapy would have been inappropriate 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 aquatic therapy have not been met.Therefore, we decided that the Plan does not have to pay foraquatic therapy provided on October 2, 2019.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a Single Photon Emission Computed Tomography (SPECT) test. 
 
You asked the Plan to pre-approve SPECT. You say that you are still having chest pain and feel very tired 
sometimes, and hope that a SPECT scan will assist in finding out the problem. The Plan denied your request. 
The Plan says that the denial of authorization for this service is correct, because the documentation does not 
show whether you have already had an exercise treadmill test or whether this test would be contraindicated. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 SPECT. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found SPECT is an appropriate and acceptable means of assessing coronary artery disease. Your 
treating provider feels this is the best test for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SPECT have been met. Therefore, we decided that the Plan has to pre-approve a 
Single Photon Emission Computed Tomography (SPECT) test.  
 
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 does not have to waive the copayment for a cystourethroscopy provided on July 14, 
2020. 
 
You asked the Plan to waive the copayment for a cystourethroscopy. You say that you feel that the service does 
not warrant a $350 copayment charge. The Plan denied your request. The Plan says the claims were processed 
correctly and you are being charged the correct 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 $350 
copayment for outpatient surgery, including services provided at hospital outpatient facilities.  
 
You have been asked to pay a $350 copayment for a cystourethroscopy. A cystourethroscopy falls within the 
outpatient surgery, including 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 cystourethroscopy provided on 
July 14, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services you received on July 
20, 2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you were unable to 
transport yourself and you cannot afford this copayment. The Plan denied your request. The Plan says you were 
charged this copayment correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 
copayment for ambulance services.  
 
You have been asked to pay a $100 copayment for the ambulance services. 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 ambulance services you received on July 20, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the ambulance transport services you 
received from January 23, 2020, to February 7, 2020. 
 
You asked the Plan to waive the copayments for the ambulance transport services. You say that these 
copayments represent a financial hardship for you. The Plan denied your request. The Plan says you were 
charged these copayments correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 
copayment per one-way trip for ambulance services.  
 
You have been asked to pay a $150 copayment per one-way trip for the ambulance transport services. 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 copayments for the ambulance transport services you received from 
January 23, 2020, to February 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the moderate sedation services and the 
dexamethasone sodium injection you received in your pain management specialist's office. 
 
You asked the Plan to waive the cost sharing for the moderate sedation services and the injection. You say that 
these services were authorized. The Plan denied your request. The Plan says you were charged this cost sharing 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for services in a specialist's office and 20% coinsurance for Medicare Part B drugs.  
 
You have been asked to pay a $30 copayment for the moderate sedation services and 20% coinsurance for the 
injection. The moderate sedation services occurred in a specialists office and the dexamethasone sodium 
injection is a Medicare Part B drug. 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 cost sharing for the moderate 
sedation services and the dexamethasone sodium injection you received in your pain management specialist's 
office.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for helicobacter pylori, breath test analysis for urease activity, 
non-radioactive isotope (83013)  helicobacter pylori, drug administration (83014) provided March 12, 2020 
 
You asked the Plan to pay for helicobacter pylori testing. You say that  The Plan denied your request. The Plan 
says there is insufficient documentation to corroborate the services and confirm that Medicare coverage has 
been met. 
 
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 83013 and 83014 is not supported in the medical record. Specifically, the 
documentation submitted does not indicate that Helicobacter pylori; breath test analysis for urease activity, 
non-radioactive isotope was performed. The documentation submitted does not indicate that nonradioactive 
isotope (C-13) was administered. The plan made multiple attempts to obtain the additional records from the 
provider to support the claim with no success. Based on this information, we decided that Medicare rules for 
coverage of helicobacter pylori infection testing have not been met. Therefore, we decided that the Plan does 
not have to pay for helicobacter pylori, breath test analysis for urease activity, non-radioactive isotope (83013)  
helicobacter pylori, drug administration (83014) provided March 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe chest x-ray provided on Jun 25, 2020.You asked the Plan to pay forthe x-ray. The Plan denied your request. The Plan says screening tests are not covered.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of thefew tests listed above, are not covered.The imaging at issue in this appeal, the x-ray, was requested solely for screening purposes. Medicare does not cover this imaging solely for screening purposes.Therefore, we decided that the Plan does not have to pay forthe chest x-ray provided on Jun 25, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve the continuation of SNF care. You say that the requested continuation of 
SNF care is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for continued SNF 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 the continuation of SNF care. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is with 
dementia, congestive heart failure, atrial fibrillation and chronic kidney disease stage 3 who was transferred to 
SNF on 11/3/20 after falls and recent right acetabular fracture. From a nursing perspective, the enrollee 
received oral medications.  The enrollee had stable vital signs. She was alert with confusion. Regarding 
rehabilitation services, the enrollee received physical therapy and occupational therapy in the SNF.  By the 
 
 
dates in question, the enrollee was at a stand by assist to moderate assist level with functional mobility 
including gait to 5 feet. The enrollee required varying assist with activities of daily living. 
 
There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. 
The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does 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 the continuation of SNF care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic screening testing provided on November 19, 2019. 
 
You asked the Plan to pay for genetic tests. You say that you are appealing with supporting documents. The 
Plan denied your request. The Plan says the denial of payment for these services is correct, because these tests 
are not a covered 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. 
 
The tests at issue in this appeal, genetic tests, were requested solely for screening purposes. Medicare does not 
cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to pay for 
genetic screening testing provided on November 19, 2019.