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

 
We decided that the Plan does not have to pay for acupuncture, one or more needles, without electrical 
stimulation, initial fifteen minutes (97810) each additional fifteen minutes, with re-insertion of needles (97811) 
provided August 11, 2020. 
 
You asked the Plan to pay for the acupuncture services. You say that according to the enrollee's plan and 
verification done on 01/02/2020 this is a covered benefit under the enrollee's plan. Please reprocess. The Plan 
denied your request. The Plan says the services were rendered by a licensed acupuncturist, not a physician. 
There is no clinical documentation supporting this acupuncture treatment was provided or supervised by a 
physician. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
twenty for CLBP meeting certain requirements, up to twelve sessions per ninety-day period, and no more than 
twenty sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As 
such, the Plans rules apply in this case.  
 
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the services must be provided by a legally qualified 
physician practicing within the scope of their license. The provider is a licensed acupuncturist, not a physician. 
There is no clinical documentation supporting this acupuncture treatment was provided or supervised by a 
physician. Therefore, we decided that the Plan does not have to pay for acupuncture, one or more needles, 
without electrical stimulation, initial fifteen minutes (97810) each additional fifteen minutes, with re-insertion 
of needles (97811) provided August 11, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to waive or reimburse the cost share for ophthalmologist services 
provided on May 6, 2019. 
 
You asked the Plan to waive or reimburse the cost share for ophthalmologist services. The Plan denied your 
request. The Plan says a review has been completed for this claim. At the time this claim processed, a total of 
$708.24 towards the maximus out of pocket had been used. This provider is part of the Plans participating 
provider organization network and these services were discounted according to the negotiated rate. Page 88-89 
of the member's 2019 evidence of coverage (EOC), states the member is responsible for $25.00 out of pocket 
for outpatient physician services for the diagnosis and treatment of diseases and injuries of the eye, including 
treatment for age-related macular degeneration. According to page 56 of the EOC, the member's in-network 
maximum out of pocket amount is $3,000 and their combined maximum out-of-pocket amount is $4,500. The 
Plan reports the claim processed 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 in 2019 there was a 
maximum out of pocket of $4500. At the time of service, the MOOP had not been met. All cost sharing applied 
was done so based on the Plan contract rules. 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 or reimburse the 
cost share for ophthalmologist services provided on May 6, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute admission to an inpatient rehabilitation facility 
(IRF).
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no indication that therapy services cannot be provided at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not require the intensity of services provided at an IRF.  Specifically, you are 
not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your 
care needs can be met at a lower level of care (ex. SNF/SAR, HHS, AL, LTC). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute admission to an inpatient rehabilitation facility (IRF)
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for glucose monitoring (95251) provided June 
30, 2020. 
 
You asked the Plan to waive the copayment for the glucose monitoring. You say that the copayment should be 
waived. The Plan denied your request. The Plan says the correct copayment was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for office visits.  
 
You have been asked to pay a $20 copayment for the glucose monitoring. The glucose monitoring falls within 
the office visits 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 glucose monitoring 
(95251) provided June 30, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for office outpatient visit (99204) provided on March 26, 2020. 
 
You asked the Plan to pay for office outpatient visit. You say that the service was medically necessary. The 
Plan denied your request. The Plan says the members claim would be covered under Original Medicare as it is 
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for office outpatient visit (99204) provided on March 26, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Adempas. 
 
You asked the Plan to pre-approve Adempas. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Adempas.  
 
Benefits for Adempas may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the DecisionDx test. 
 
You asked the Plan to pay for the DecisionDx test. You say that you would like reconsideration because this 
test is necessary to help determine the most appropriate management for the member. The Plan denied your 
request. The Plan says there is no definable purpose or medical necessity for performing the testing. 
 
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 test. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found it remains unclear whether commercially available gene expression profile platforms provide 
clinically actionable prognostic information when used in addition to or in comparison with known 
clinicopathologic factors or multivariable nomograms that incorporate patient sex, age, tumor location and 
thickness, ulceration, mitotic rate, lymphovascular invasion, microsatellites, and sentinel lymph node biopsy 
status. Furthermore, the impact of these tests on treatment outcomes or follow-up schedules has not been 
established. 
 
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 test have not been met. Therefore, we decided that the Plan 
does not have to pay for the DecisionDx test.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that you would like reconsideration 
because the member's condition is getting worse The Plan denied your request. The Plan says this is not a 
Medicare covered benefit. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6549.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Myrbetriq. 
 
You asked the Plan to pre-approve Myrbetriq. You say that despite advanced treatments, only a combination of 
Vesicare and Myrbetriq helps. You say that other medications will not address the enrollee's problem. The Plan 
denied your request. The Plan says the member has not tried and failed the step therapy formulary drugs. 
 
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 Myrbetriq. Our reviewer says that the 
enrollee has not tried and failed the required drugs tolterodine, oxybutynin and trospium. Our physician 
reviewer found there is no documentation provided indicating that the required drugs will be less effective or 
have adverse effects. 
 
 
  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Myrbetriq have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Myrbetriq.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc. 
 
You asked the Plan to pre-approve Synvisc. You say that the injections are requested to help with knee pain. 
The Plan denied your request. The Plan says the enrollee would need to try and fail Euflexxa in order to qualify 
for Synvisc. 
 
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 Synvisc. Our reviewer says that the 
enrollee has not trialed Euflexxa. Step therapy, as outlined by the Plan, requires this be trialed first. Our 
physician reviewer found that the documentation does not outline reasons this medication was not considered. 
Without the support of the documentation, Synvisc is not approved, as step criteria have 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 Synvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Synvisc.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the air transportation (A0431 and A0436) provided on March 
27, 2020. 
 
You asked the Plan to pay for the air transportation. You say that you would like reconsideration because this 
claim was billed correctly. The Plan denied your request. The Plan says payment is not allowed for this service 
because it was billed without a zip code for the point of pick up. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code A0431 and A0436 is not supported in the record. Specifically, this claim did not include 
the required zip code for the point of pick up. Based on this information, we decided that Medicare rules for 
coverage of the air transportation have not been met. Therefore, we decided that the Plan does not have to pay 
for the air transportation (A0431 and A0436) provided on March 27, 2020.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the services (CPT 94726) provided on October 2, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the billed code 
cannot be verified. 
 
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 94726 is "Plethysmography for determination of lung volumes and, when performed, airway resistance". 
 
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 use 
of CPT code 94726 is supported by the records provided. Our physician reviewer found that the documentation 
notes that pulmonary functions tests (PFTs) were performed. The documentation does not specifically note 
which PFTs were performed. However, different PFTs provide different test results, which, when provided, can 
be used to determine which PFTs were performed. In this case, the health plan has paid for spirometry, 
diffusion capacity and pulmonary stress tests, which would be supported by the FEV1, FVC, DLCO and 
6MWT results. The remaining test results, RV and TLC, would support that plethysmography was performed, 
as these results are not obtained by the other tests. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
the services (CPT 94726) provided on October 2, 2019.  
 
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 pontics (D6245) for tooth #'s 9 and 10 and retainer 
crowns (D6740) for tooth #'s 8 and 11. 
 
You asked the Plan to pre-approve the pontics and retainer crowns. You say that a bridge is needed because 
your current dentures are causing cavities. The Plan denied your request. The Plan says the information 
provided does not say why a denture cannot be used to replace your missing teeth. The Plan also says that 
retainer crown (D6740) is not covered under your benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the pontics 
and retainer crowns 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 pontics. Our reviewer says that the 
pontics are not medically reasonable and necessary. Our physician reviewer found it is clear that a fixed 
appliance would not be necessary where a removable appliance has been functional. Our reviewer found that 
the existence of decay around abutments is not a viable reason to place fixed bridgework, and in fact a high 
decay rate is a contraindication to fixed appliances. Our physician reviewer also found that as a removable 
appliance has functioned in the past, a fixed appliance would not be considered medically necessary. 
 
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 pontics and retainer crowns have not been met. Therefore, we decided that 
the Plan does not have to pre-approve pontics (D6245) for tooth #'s 9 and 10 and retainer crowns (D6740) for 
tooth #'s 8 and 11.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on 
October 2, 2020. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you did not see a 
specialist so you should not have a $45 copayment. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
copayment for provider and professional services at an in-network specialist's office.  
 
You have been asked to pay a $45 copayment for the specialist office visit. The specialist office visit falls 
within the ?Physician/Practitioner services, including doctor?s office visits? benefit category. The record shows 
you were seen by a Physician?s Assistant at a cardiology center which is considered a specialty. 
 
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 office visit provided on October 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endodontic therapy (D3330) provided on August 5, 2020. 
 
You asked the Plan to pay for the endodontic therapy. You say that you had a severe toothache, and went to the 
dentist for relief of the pain. You also say that the procedure was started, but was not completed until 
September after the dental rider took effect. The Plan denied your request. The Plan says this service is not a 
covered benefit under your dental plan. The Plan also says that you did not become effective with the 
supplemental dental rider until September 1, 2020. 
 
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 
endodontic therapy (D3330) provided on August 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the preventive procedure, problem focused limited oral 
evaluation, and extraction provided on August 26, 2020. 
 
You asked the Plan to pay for the preventive procedure, problem focused limited oral evaluation, and 
extraction. You say that you did not receive any services on August 26, 2020. The Plan denied your request. 
The Plan says your request is not a covered benefit because Medicare does not cover routine dental services, 
and your plan does not include a dental supplement. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the preventive procedure, 
problem focused limited oral evaluation, and extraction provided on August 26, 2020.  
 
Please Note: Your appeal states that you believe the claim in dispute was fraudulent, as you never received the 
services billed. Medicare only permits us to make determinations regarding coverage through the Plan. You 
may contact the Kansas City CMS Regional Office with any concerns of fraudulent billing.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a history of head and 
neck cancer. He had a prior PET scan on 2019 that is negative. There is no indication in the submitted 
documentation to support a chest CT at this time. 
 
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 a computed tomography (CT) scan of the chest.