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

We decided that the Plan does not have to pay for the advanced care planning rendered on December 23, 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 99497 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 99497 is advance care planning including the explanation 
and discussion of advance directives such as standard forms (with completion of such forms, when performed), 
by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, 
family member(s), and/or surrogate. 
 
We find that CPT code 99497 is not supported in the medical record. Specifically, there is no documentation of 
discussion between the provider and the patient regarding eventual end of life decisions. 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 advanced care planning rendered on December 23, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on September 3, 2019. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with records. The Plan denied your 
request. The Plan says the denial of payment for these services is correct, because the documentation submitted 
does not include a valid physician order or lab requisition for the tests billed and does not support the Place of 
Service (POS) code billed on this claim. 
 
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 lab tests have not been met. Therefore, we decided that the Plan 
does not have to pay for laboratory testing provided on September 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist visit provided on April 14, 
2020. 
 
You asked the Plan to waive the copayment for the specialist visit. The Plan denied your request. The Plan says 
the copayment applied 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 $40 
copayment for services obtained from a specialist.  
 
You have been asked to pay a $40 copayment for the specialist visit. The specialist visit falls within the 
"Physician/Practitioner Services, Including Doctors Office Visits" benefit category. The Plan says that only 
copayments for physicians services between May 11, 2020, and September 30, 2020 will be waived. 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 specialist visit provided on April 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient mental health care for the enrollee. 
 
You asked the Plan to pre-approve continued inpatient mental health care. You say that these services are 
medically necessary for the enrollee. The Plan denied your request. The Plan says that the enrollee has 
exhausted their 190-day lifetime limit for inpatient services in a psychiatric hospital. 
 
The Plan must follow Medicare rules. The rules say that there is a lifetime maximum of 190 days on inpatient 
psychiatric hospital services available to any beneficiary and once an individual receives benefits for 190 days 
of care in a psychiatric hospital, no further benefits of that type are available to that individual.  
 
The file shows that the enrollee received 190 days of inpatient psychiatric hospital services.  
 
Although the enrollee may still need inpatient psychiatric hospital services, the Plan is not required to pay for 
more than 190 days of inpatient psychiatric hospital services. Therefore, we decided that the Plan does not have 
to pre-approve continued inpatient mental health care for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Prolia 60 mg/ml subcutaneous syringe provided. 
 
You asked the Plan to pay for Prolia. You say that he enrollee has memory issues. You say that the enrollee is 
not able to stay compliant with the oral treatment. You say that she only makes it to her appointments because 
of multiple reminders. You also say that the enrollee would benefit from receiving Prolia when she comes to 
the office. The Plan denied your request. The Plan says the criteria for coverage has 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 Prolia. Our reviewer says that the Prolia 
 
 
does not meet the criteria for coverage. Our physician reviewer found the enrollee has not tried and failed the 
required drug(s), an oral biophosphonate drug and zolendronic acid. The reviewer found there is no 
documentation provided indicating that the Plan?s required drug(s) would likely be less effective and/or likely 
have adverse effects for the enrollee. Therefore, the reviewer found that the criteria for coverage has not been 
met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pay for Prolia 60 mg/ml subcutaneous syringe provided.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tecentriq for the enrollee. 
 
You asked the Plan to pre-approve Tecentriq. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the denial was appropriate given the guidance presented above and the fact that the 
enrollee did progress in the face of prior PD-1/PD-L1 treatment. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Tecentriq. Our reviewer says that 
Tecentriq is not medically reasonable and necessary for the enrollee in this case. Tecentriq is being requested to 
treat progressive metastatic non-small cell lung cancer which has progressed on platinum based chemotherapy 
including Keytruda. The submitted records do not include information regarding molecular markers such as 
EGFR, ROS, ALK. The submitted information does not permit determination whether the requested use meets 
the FDA approval due to lack of molecular test information. The requested use does not permit determination 
whether the requested use meets the CMS approved compendium usage due to lack of molecular test 
information. The NCCN compendium states the drug should be used if there has been no prior progression on a 
PD-1/PDL-1 inhibitor. The enrollee has progressed on Keytruda which is in that drug class. Therefore, the 
NCCN compendium lists the drug as not supported for the requested use. Our physician reviewer found that the 
enrollee's condition does not meet Medicare criteria for Tecentriq. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Tecentriq have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Tecentriq for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services (CPT 99358) provided 
to the enrollee on November 29, 2019. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 99358 (1 Unit) remains 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 99358 is prolonged evaluation and management service 
before and/or after direct patient care; first hour.
 
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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our coding reviewer found CPT 99358 
is reported by time. To confirm prolonged service, time should be documented in the evaluation and 
management note. 
 
We looked at this coder'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 pay for evaluation and management services (CPT 99358) provided to the enrollee on November 29, 
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 is medically necessary. The Plan denied your 
request. The Plan says your needs could be met 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 based on the documentation provided, you 
have no identifiable skilled nursing or therapy service needs. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on March 5, 
2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 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 
to the enrollee on March 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for progressive lens and frame services on August 24, 2020 from 
an out-of-network provider. 
 
You asked the Plan to pay for progressive lens and frame services. You say that you believe the discount the 
provider offered you was from insurance. The Plan denied your request. The Plan says there is no coverage or 
payment for lens options/enhancements with an out of network provider. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services only every two years from an in network provider. 
 
We looked at the file and the Plan's rules. We have found that you have used an out-of-network provider for 
your lens options/enhancements. Based on this information, we decided that the Plan's rules for coverage of 
progressive lens and frame services have not been met. Therefore, we decided that the Plan does not have to 
pay for progressive lens and frame services on August 24, 2020 from an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99213) provided March 8, 2018. 
 
You asked the Plan to pay for the office visit. You say that the claim should be paid. The Plan denied your 
request. The Plan says the claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the office visit was not filed until November 13, 2019. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for an office visit (99213) provided March 8, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete lower denture (D5120). 
 
You asked the Plan to pre-approve the dental item. You say that the enrollee has gum disease and cannot eat 
solid food. You say that the enrollee has not had any dental services besides the extractions. You also say that 
the dentures is medically necessary. The Plan denied your request. The Plan says dentures are excluded from 
coverage. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested denture is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a complete 
lower denture (D5120).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the diagnostic colonoscopy provided on 
June 24, 2020. 
 
You asked the Plan to reduce the copayment for the diagnostic colonoscopy. You say that you were supposed 
to have the colonoscopy at the surgical center but had to reschedule at the hospital. You say that now your bill 
is $350 instead of $275. The Plan denied your request. The Plan says the copayment applied 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 $350 
copayment for an outpatient hospital facility. 
 
You have been asked to pay a $350 copayment for the diagnostic colonoscopy. The diagnostic colonoscopy 
falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers" benefit category. The colonoscopy was performed at the hospital. 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 reduce the copayment for the diagnostic colonoscopy provided on June 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for durable medical equipment provided by an 
out-of-network provider on August 7, 2019. 
 
You asked the Plan to waive the coinsurance for durable medical equipment. You say that you do not agree 
with the coinsurance that was applied. The Plan denied your request. The Plan says the correct coinsurance has 
been 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). The enrollee's contract with the Plan clearly says that enrollees 
must pay a 42% coinsurance for durable medical equipment/out-of-network.  
 
The enrollee has been asked to pay a 42% coinsurance of the allowed amount for durable medical equipment. 
The total allowed amount is $299.26. The total amount you are being asked to pay is $125.70 ($299.26 x 42% 
= $125.70). Durable medical equipment falls within the durable medical equipment/out-of-network benefit 
category. This means that the enrollee has been asked to pay the correct amount based on the contract with the 
Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. 
Therefore, we decided that the Plan does not have to waive the coinsurance for durable medical equipment 
provided by an out-of-network provider on August 7, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses received on July 20, 2020. 
 
You asked the Plan to pay for the eyeglasses. You say that you feel you were overcharged. The Plan denied 
your request. The Plan says the claim was processed correctly per your plan benefits. 
 
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 the plan has a $250 eye 
wear limit and that you must pay anything over $250 for vision care.  
 
You have been asked to pay anything over $250 for the eyeglasses. The eyeglasses fall within the vision care 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. Review of the file shows that the total amount for the eyeglasses was $507. The plan paid the eye 
wear amount of $250. Therefore, you have been asked to pay the remainder $257. 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 pay for the eyeglasses received on July 20, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on February 
17, 2020. 
 
You asked the Plan to pay for the ambulance services.  The Plan denied your request. The Plan says these 
services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on February 17, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on 
February 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first intraoral periapical x-ray, additional intraoral 
periapical x-ray, re-cement or re-bond fixed partial denture, complete series of intraoral x-rays, and problem 
focused limited oral evaluation provided from April 8, 2020, to June 24, 2020 by an OON provider. 
 
You asked the Plan to pay for the intraoral periapical x-rays, re-cement or re-bond fixed partial denture, and 
problem focused limited oral evaluation. You say that you were told that you had dental coverage, and believe 
the Plan has falsely advertised the dental coverage. The Plan denied your request. The Plan says the first 
intraoral periapical x-ray, additional intraoral periapical x-ray, re-cement or re-bond fixed partial denture, and 
complete series of intraoral x-rays are not covered under your plan. The Plan also says that you are responsible 
for the $30 deductible and $15 cost in excess of the allowed amount for the problem focused limited oral 
evaluation. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the first intraoral periapical x-ray, 
additional intraoral periapical x-ray, re-cement or re-bond fixed partial denture, and complete series of intraoral 
x-rays are not among those covered under this benefit. The contract also clearly states that you are responsible 
for a $100 dental deductible, and 50% coinsurance for each dental service rendered by an OON provider. 
Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray, additional 
 
 
intraoral periapical x-ray, re-cement or re-bond fixed partial denture, complete series of intraoral x-rays, and 
problem focused limited oral evaluation provided from April 8, 2020, to June 24, 2020 by an OON provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services (G0299).

You asked the Plan to pre-approve the home health services. You say that the services are medically necessary. The Plan denied your request. The Plan says coverage criteria is not met.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

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 home health services. Our reviewer says that additional home health services are not medically necessary. Our physician reviewer found the documentation doesn't support that the enrollee requires skilled nursing services or skilled rehab services to provide treatment that is 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 the home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health services (G0299).