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

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on December 19, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network 
deficiency for these services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider 
on December 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical nutrition therapy. 
 
You asked the Plan to pre-approve medical nutrition therapy services. You say that your doctor recommended 
this to help you gain weight. The Plan denied your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
The records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan 
does not have to pre-approve medical nutrition therapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an immediate maxillary partial denture for the enrollee. 
 
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 a covered benefit. 
 
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 an 
immediate maxillary partial denture for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for lab services received on April 1, 2020 and 
April 2, 2020. 
 
You asked the Plan to waive the copayments for the services. You say that both services occurred on April 2, 
2020, so there should only be one copayment. The Plan denied your request. The Plan says there is a $7 
contractual copayment for Medicare-covered lab tests. 
 
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 $7 
copayment for laboratory services.  
 
You have been asked to pay a $7 copayment for each of the dates of service. The file shows that lab services 
were rendered on two separate days. The services fall within the laboratory services 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 lab services received on April 1, 2020 and April 2, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve hallux valgus correction foot surgery. 
 
You asked the Plan to pre-approve the foot surgery. You say that the treatment team has recommended that 
surgical correction of this Hallux Valgus is medically necessary. The Plan denied your request. The Plan says 
that the requested surgery is not considered medically necessary. 
 
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 the foot surgery. Our reviewer says that 
hallux valgus correction right side is considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee is diagnosed with a painful hallux valgus right side. Clinically, the enrollee is 
experiencing pain to the bunion deformity. The enrollee demonstrates incongruent first MPJ with a very high 
intermetatarsal angle noted on x-ray. 
 
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 foot surgery have been met. Therefore, we decided that the Plan has to pre-
approve hallux valgus correction foot surgery.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on September 24, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network 
deficiency for these services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider 
on September 24, 2019.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approve the IV sedation services. We decided that the Plan does not have to pre-approve the endosteal implants, second stage implant surgeries, and semi-precision attachment abutments.
You asked the Plan to pre-approve the IV sedation services, endosteal implants, second stage implant surgeries, and semi-precision attachment abutments. You say that the enrollee cannot keep their lower denture in. You also say that the enrollee is unable to eat and is not getting proper nutrition. The Plan says that the records do not clearly show that IV sedation services are needed. The Plan also says that endosteal implant, second stage implant surgery, and semi-precision attachment abutment are not covered benefits
We decided that the Plan has to pre-approve the IV sedation services.
The Plan follows Medicare rules. Medicare rules say that health plans must provide you with a clear and
accurate description of the benefits offered under the Plan. The contracts do not say in clear and accurate terms
the limitations that are being referenced in the denial.
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 IV sedation services have been met. Therefore, we decided that the Plan has
to pre-approve the IV sedation services.
We also decided that the Plan does not have to pre-approve the endosteal implants, second stage implant
surgeries, and semi-precision attachment abutments.
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
endosteal implants, second stage implant surgeries, and semi-precision attachment abutments.
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic digital breast tomosynthesis (77062) provided on 
February 10, 2020. 
 
You asked the Plan to pay for the diagnostic breast tomosynthesis. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says CPT code 77062 has a status 
indicator of I and is not valid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 77062 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT 
code 77062 has a status indicator of I. This means that CPT code 77062 is not valid for Medicare purposes. 
Based on this information, we decided that Medicare rules for coverage of the diagnostic breast tomosynthesis 
have not been met. Therefore, we decided that the Plan does not have to pay for diagnostic digital breast 
tomosynthesis (77062) provided on February 10, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on December 20, 2019. 
 
You asked the Plan to pay for the lab services. 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 the few 
tests listed above, are not covered. 
 
The lab services at issue in this appeal were requested solely for screening purposes. Medicare does not cover 
this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab 
services provided on December 20, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on March 3, 2020. 
 
You asked the Plan to pay for the services. You say that the enrollee had active coverage on the date of service, 
and shouldn't be held liable for any charges. The Plan denied your request. The Plan says Medicare says non-
urgent services should be from network providers who are contracted with the healthplan and listed in the 
Provider Directory. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on March 3, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for tracheostomy supplies (A4623, A7521 and A7526) provided
on March 11, 2020.
You asked the Plan to pay for tracheostomy supplies. You say that you would like reconsideration because
these supplies are medically necessary. The Plan denied your request. The Plan says payment for these supplies
is included in the Part A SNF payment.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.
Records show that tracheostomy supplies was used in a SNF or hospital. When DME is furnished for use in an
SNF during a covered Part A stay, no separate payment shall be made. Therefore, we decided that the Plan
does not have to pay for tracheostomy supplies (A4623, A7521 and A7526) provided on March 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (HCPCS G0249) provided to the enrollee on February 10, 2020.
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 the service was billed less than 25 days.
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 HCPCS code G0249 is "Provision of test materials and equipment for home INR monitoring of patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria; includes: provision of materials for use in the home and reporting of test results to physician; testing not occurring more frequently than once a week; testing materials, billing units of service include 4 tests." We find that HCPCS code G0249 is not supported in the medical record. Specifically, the service was billed for less than 25 days. 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 laboratory services (HCPCS G0249) provided to the enrollee on February 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the porcelain crown (D2750) provided
February 4, 2020.
You asked the Plan to waive the copayment for the crown. You say that you live in the city and you should not
have to go all over to get coverage. The Plan denied your request. The Plan says this claim was processed
correctly per the 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 you must pay 50%
copayment for crowns. The health plan contract also says that benefits received out-of-network are subject to
any in-network benefit maximums, limitations and/or exclusions. You may be billed more by an out-of-network
provider if the charge is greater than maximum allowable charge.
You have been asked to pay $632.50 for the crown. The crown falls within the Dental services 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 the porcelain crown (D2750) provided
February 4, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nucala pre-filled syringes for self-administration.
You asked the Plan to pre-approve self-administered drugs. You say that the enrollee needs this drug to treat her condition. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.
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 Nucala pre-filled syringes for self-administration.
Benefits for self-administered drugs 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient surgical admission.
You asked the Plan to pre-approve the inpatient surgical admission. You say that it is medically necessary for the procedure to be performed inpatient. The Plan denied your request. The Plan says the medical information received does not support the bladder procedure at an inpatient setting.
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 inpatient surgical admission. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was to be admitted on August 12, 2020 for IV antibiotics prior to cystoscopy to be performed August 13, 2020. The enrollee's provider required inpatient level of care services. There was no documentation provided necessitating inpatient level of care services. The enrollee was hemodynamically stable without evidence of sepsis. She required no inpatient diagnostic studies or therapeutic interventions. The enrollee's care can be appropriately provided at a less intense level of care, such as observation. 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 inpatient surgical admission have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient surgical admission.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synthroid tablets.
You asked the Plan to pre-approve self-administered drug. You say that you are appealing. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drugs.
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 Synthroid tablets.
Benefits for self-administered drug 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for advance care planning (99497) provided on January 22, 2020.
You asked the Plan to pay for the advance care planning. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted documentation does not include the documentation of a discussion between the provider and the patient, along with family member(s), or surrogate(s), regarding eventual end-of-life decisions and preferences.
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 record. Specifically, the record does not indicate that advance care planning services were rendered on the billed date of service. Based on this information, we decided that Medicare rules for coverage of the advance care planning have not been met. Therefore, we decided that the Plan does not have to pay for advance care planning (99497) provided on January 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (99291 and 99292) provided on January
26, 2020.
You asked the Plan to pay for the critical care services. You say that you would like reconsideration based on
the records submitted. The Plan denied your request. The Plan says the documentation submitted does not
support the services billed.
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 99291 is critical care, evaluation and management of the
critically ill or critically injured patient; first 30-74 minutes.
The CPT Code Manual definition of code 99292 is critical care, evaluation and management of the critically ill
or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service).
We find that CPT codes 99291 and 99292 are not supported in the record. Specifically, the documentation
submitted does not support that 30-74 minutes of critical care services were rendered on the billed date of
service. CPT code 99292 is not supported because the required primary service is denied. Based on this
information, we decided that Medicare rules for coverage of the critical care services have not been met.
Therefore, we decided that the Plan does not have to pay for critical care services (99291 and 99292) provided
on January 26, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to
the enrollee on April 1, 2020.
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request.
The Plan says Medicare requires use of CPT 81479 to report a Guardant360 molecular pathology genomic
profiling for breast cancer, and the appropriate DEX Z-Code identifier must be entered adjacent to the CPT
code [81479] in the comment/narrative field
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare
rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay
for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on April 1, 2020.