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

 
We decided that the Plan does not have to pre-approve molecular pathology procedures (81404, 81479). 
 
You asked the Plan to pre-approve molecular pathology procedures. You say that the services are necessary. 
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan follows Medicare rules. Medicare rules say that molecular pathology procedures (Tier1 and Tier 2) 
may be eligible for coverage when specific criteria is 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 molecular pathology procedures. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found a review of the 
current medical literature indicates that this genetic testing would not directly impact treatment or management 
and although this testing is useful to confirm a diagnosis, the treatment of this disorder is supportive based on 
symptoms. The review has determined that the enrollee does not meet the coverage 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 molecular pathology procedures have not been met. Therefore, we decided that 
the Plan does not have to pre-approve molecular pathology procedures (81404, 81479).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to be held harmless for the laser destruction of leaking retinal blood vessels 
(67228) provided on March 3, 2020. 
 
You asked the Plan to be held harmless for the laser destruction of leaking retinal blood vessels. You say that 
you tried to gain prior authorization for this service. The Plan denied your request. The Plan says that since you 
did not receive a referral from your primary care physician, this service cannot be covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
In this case, the file does not show that the Plan provided notice that the laser destruction of leaking retinal 
blood vessels would not be covered. In addition, the Plan contracted provider states that they attempted to 
obtained prior authorization but were told by a Plan representative that prior authorization was not required. 
Under Medicare rules, this means the laser destruction of leaking retinal blood vessels is considered approved 
by the Plan. Therefore, we decided that the Plan has to be held harmless for the laser destruction of leaking 
retinal blood vessels (67228) provided on March 3, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the periodontal scaling and root planing (D4341) for the 
upper left quadrant. 
 
You asked the Plan to pre-approve the dental service. You say that you have diabetes. You say that you need 
this service because your gums will not heal. The Plan denied your request. The Plan says periodontal scaling 
and root planing is not listed as a covered service. 
 
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 the 
periodontal scaling and root planing (D4341) for the upper left quadrant.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services provided on March 3, 2020, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for outpatient hospital services. You say that you would like this claim reprocessed 
and paid. The Plan denied your request. The Plan says prior authorization was obtained by the facility or the 
provider. 
 
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 outpatient hospital services provided on March 3, 
2020, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for ultrasounds provided. 
 
You asked the Plan to waive the copayments for ultrasounds. You say that you disagree with the increase in 
charges. 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 $155 
copayment for each radiological diagnostic service. 
 
You received two ultrasounds. Therefore, you are responsible to pay the total allowed amount 
of $238.22, which is less than the total copayment amount.   
 
You have been asked to pay $238.22 for ultrasounds. Ultrasounds fall 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 copayments for 
ultrasounds provided.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Percutaneous implantation of neurostimulator electrode 
array, epidural (63650) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that records do no show the enrollee is a good candidate for this 
procedure. 
 
The Plan follows Medicare rules. Medicare rules say that dorsal column stimulators are covered if the above 
criteria have been 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 
these services are not medically reasonable and necessary for the enrollee. The patient does NOT have a 
surgical consultation documented even though there are several disc herniations/extrusions. The patient does 
not have an evidence based indication for a spinal cord stimulation placement. Our physician reviewer found 
that the enrollee's condition does not meet Medicare criteria for these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Percutaneous implantation of neurostimulator electrode array, epidural (63650) for the 
enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve High Intensity Focused Ultrasound (HIFU) treatment 
(C9747, 55880). 
 
You asked the Plan to pre-approve HIFU treatment. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that whole gland HIFU is considered medically necessary 
when specific criteria is 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 HIFU treatment. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found based on NCCN guidelines and the lack 
of high level evidence, HIFU would not be an accepted standard of care. More importantly, the LCD is explicit 
in covering HIFU only for recurrence after biopsy proven prior radiotherapy. As such, the coverage criteria are 
not 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 HIFU treatment have not been met. Therefore, we decided that the Plan does 
not have to pre-approve High Intensity Focused Ultrasound (HIFU) treatment (C9747, 55880).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 88312, CPT 88305) provided on January 
21, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a duplicate 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined 
to be exact duplicates of another claim or claim line are denied.  
 
We looked at the file and Medicare rules. The records show that the services in question were billed on a 
duplicate claim to one previously processed and paid by the Plan. Duplicate claims are not payable. 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 the services (CPT 88312, CPT 88305) provided on January 21, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete maxillary and mandibular denture. 
 
You asked the Plan to pre-approve the dentures. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not approved since the requested services exceed the maximum count allowed per 
period. 
 
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 dentures once 
every five years. 
 
Complete dentures were last received on January 21, 2019. This is less than five years ago. Based on this 
information, we decided that the Plan's rules for coverage of the dentures have not been met.  Therefore, we 
decided that the Plan does not have to pre-approve complete maxillary and mandibular denture.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive periodontal exam (D0180) and gingival 
irrigation per quadrant (D4921 x 2) provided on September 21, 2020. 
 
You asked the Plan to pay for the dental services. You say that you were only in the office for 30 minutes. You 
say that you did not have a deep cleaning done. You say that you had to pay $140 upfront. You also say that 
you are being charged for services that you did not receive. The Plan denied your request. The Plan says 
gingival irrigation is not listed as a covered service. The Plan says that the comprehensive periodontal exam is 
not listed as a covered service either. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. The Evidence of Coverage clearly states that any services not listed are 
not covered. Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal exam 
(D0180) and gingival irrigation per quadrant (D4921 x 2) provided on September 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-
network provider. 
  
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says you 
must receive care from in-network providers with the exception of emergency or urgent care, dialysis while 
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which 
requires prior authorization from the plan. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by the out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiovascular risk assessment services provided on June 6, 
2020 and billed under codes 81407 and 81408. 
 
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 this claim should be paid because the services billed are not covered by Medicare.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case the codes billed are for a cardiovascular 
screening that is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for 
cardiovascular risk assessment services provided on June 6, 2020 and billed under codes 81407 and 81408.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on June 23, 2020. 
 
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
The Plan must follow Medicare rules. Medicare rules say that a Marriage Family Therapist (MFT) is not 
eligible to participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Marriage Family Therapist 
(MFT).  Medicare says that a Marriage Family Therapist (MFT) is not eligible to participate in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for psychotherapy services provided on June 
23, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the information submitted does not meet the guidelines for coverage. 
 
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 the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the plan requires a trial 
of Zoledronic Acid before they will approve the requested drug. In this case, there is no documentation 
provided indicating that the patient tried and failed the required drug. There is no documentation provided 
indicating that the Plan's required drug would likely be less effective and/or likely 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 the drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Prolia for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Orthovisc (hyaluronan). 
 
You asked the Plan to pre-approve Orthovisc. You say that you are still in pain and your provider feels the 
additional injections will help. The Plan denied your request. The Plan says the denial of authorization for this 
drug is correct, because there is not documentation of positive clinical response to therapy or that at least 6 
months have passed since the prior course of treatment. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Orthovisc. Our reviewer says that you 
do not meet the Medicare criteria for Orthovisc. Our physician reviewer found the records do not document the 
degree of functional improvement with previous injections. More information is needed to justify repeat 
injection. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orthovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Orthovisc (hyaluronan).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 
 
You asked the Plan to pay for the dental service. You say that the providers office did not tell you that you had 
met your benefit maximum. You also say that you should have been forewarned that you were this close to 
your annual maximum before the service was rendered. You also say that you cannot afford to pay this bill. 
The Plan denied your request. The Plan says there is an annual maximum of $1,000 for covered dental services. 
The Plan says that the annual maximum has been exhausted. 
 
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 annual maximum of $1,000 for 
covered dental services has been exhausted. The record shows that the Plan paid $73 for dental services that 
you received on February 11, 2020, $172.70 for dental services you received on July 9, 2020, and $754.30 for 
dental services you received on July 16, 2020. The payment of these services has exhausted your annual 
maximum. Additionally, the Explanation of Benefits includes an accumulation of how much of the $1,000 
benefit that has been used. Therefore, we decided that the Plan does not have to pay for the filling (D2394 x 3) 
provided on August 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve visual field assessment for the enrollee. 
 
You asked the Plan to pre-approve the assessment. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not covered, which is supported by extensive literature. 
 
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 assessment. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found daily use of an Amsler Grid may allow for earlier detection of leakage or progression of age-
related macular degeneration. However, such testing has not been clearly shown to result in changes in 
management and patient outcomes. 
 
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 assessment have not been met. Therefore, we decided that the Plan does not 
have to pre-approve visual field assessment for the enrollee.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan with quantitative evaluation of 
coronary calcium (75571). 
 
You asked the Plan to pre-approve a CT scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 a CT scan. Our reviewer says that the 
requested CT scan is medically necessary. Our physician reviewer found the patient has an elevated 10 year 
risk of cardiovascular disease and is 77 years old. His LDL cholesterol is in the intermediate range where 
guidelines suggest that a CT calcium score may be a reasonable adjunctive test to assess the need for starting a 
statin medication at his advancing age. The CT calcium scan is therefore medically reasonable and necessary 
and is in accordance with CMS medical necessity coverage criteria outlined for this diagnostic test. A low 
calcium score would likely obviate the need for lifelong statin therapy in this patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CT scan have been met. Therefore, we decided that the Plan has to pre-
approve a computed tomography (CT) scan with quantitative evaluation of coronary calcium (75571).  
 
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.