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

 
We decided that the Plan does not have to pay for the lipid panel (80061), complete blood count (85025) and 
comprehensive metabolic panel (80053) provided on May 21, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for lipid panel, complete blood count and comprehensive metabolic panel. You say 
that medically necessary services were rendered in good faith. The Plan denied your request. The Plan says 
prior authorization must be obtained for non-emergent services rendered by an out-of-network 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 the lipid panel (80061), complete blood count 
(85025) and comprehensive metabolic panel (80053) provided on May 21, 2020 by an out of network (OON) 
provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infection agent detection services provided to the enrollee on 
December 16, 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 the clinical value of PCR testing in the setting of fungal nails remains unproven in the medical 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found Medicare guidelines state that they do cover treatments for malformed body parts in particular situations. 
In this particular case, onychomycosis may be identified with simple testing including physical exam, KOH 
and or fungal cultures. PCR testing, while very accurate, appears to be excessive in this particular case. 
Medicare guidelines specifically advise that it will only cover treatments or testing that meets, but does not 
exceed the enrollee's medical needs. PCR testing for onychomycosis is an excessive test. It is not standard 
medical practice to perform a PCR test on every mycotic toenail. Diagnosis of onychomycosis can be achieved 
via clinical exam, physical findings of the affected toenail, KOH testing, and simple fungal culture testing. For 
this reason, the PCR testing for this enrollee's toenail specimen is not medically reasonable or 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for infection agent detection services provided to the enrollee on December 16, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve GEL-ONE (J7326). 
 
You asked the Plan to pre-approve GEL-ONE. You say that the requested drug is medically necessary. The 
Plan denied your request. The Plan says Gel-One is not a preferred viscosupplement. The Plan says the enrollee 
has not tried and failed the preferred drugs. The Plan also says that the requested drug is not medically 
necessary. 
 
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 GEL-ONE. Our reviewer says that the 
requested drug is not medically necessary. Our physician reviewer found the provided documentation does not 
show that the enrollee has trialed the required viscosupplemental treatments such as Orthovisc and Monovisc.  
 
 
 
 
The reviewer found that the documentation does not outline contraindications or reasons these medications 
were not considered. The reviewer also found that without the support of the documentation, Gel-One 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 GEL-ONE have not been met. Therefore, we decided that the Plan does not 
have to pre-approve GEL-ONE (J7326).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility discharge management (99316) provided 
on November 4, 2019, by an out of network (OON) provider. 
 
You asked the Plan to pay for the nursing facility discharge management. You say that the services provided 
were medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained by 
the facility or the provider; therefore, payment has been correctly denied. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the nursing facility discharge management 
(99316) provided on November 4, 2019, by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve 10 additional PT visits. You say that the additional visits are medically 
necessary. The Plan denied your request. The Plan says additional PT visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve 10 additional PT visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found the requested therapy is not generally accepted as specific 
and effective therapy for the patient?s condition. The documentation does not support that the patient's 
functional level requires the unique skills of a professional therapist to safely and effectively provide treatment, 
that the services can be safely and effectively performed only by a therapist, or under the supervision of a 
therapist. The  specialized skill, knowledge and judgment of a qualified therapist is not required to establish, 
design and/or deliver a program to maintain the patient's current condition or to prevent or slow further 
deterioration. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 10 additional PT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 10 additional physical therapy (PT) visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary visit (99328) provided on May 22, 2020 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for domiciliary visit. You say that medically necessary services were rendered in 
good faith. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent 
services rendered by an out-of-network 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 the domiciliary visit (99328) provided on May 22, 
2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the full amount for the periodic oral evaluation (D0120), 
prophylaxis (D1110), and the bitewing x-rays (D0274) provided on July 15, 2020. 
 
You asked the Plan to pay the full amount for the dental services. You say that based on the information in the 
Quick Start Guide, in network and out of network service have the same coverage. You say that you did not ask 
the dentist if they were in network because you did not think that it mattered. You also say that you would like 
more comprehensive information about your coverage as you cannot rely on the information in the guide that 
was provided. The Plan denied your request. The Plan says for services covered under the plan, you may still 
be billed by an out of network provider for any amount greater than the maximum allowable charge payment 
made by the Plan to the provider. The Plan also says that the claim processed correctly. 
 
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, you may still be billed by an out of 
network provider for any amount greater than the maximum allowable charge payment made by the Plan to the 
provider. 
 
CPT Code Billed Amount Allowed Amount Plan Paid Your Responsibility 
D0120 $119 $57 $57 $62 
D1110 $65 $26 $26 $39 
D0274 $91 $36 $36 $55 
TOTAL:    $156 
 
 
Therefore, we decided that the Plan does not have to pay more for the periodic oral evaluation (D0120), 
prophylaxis (D1110), and the bitewing x-rays (D0274) provided on July 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the visit you had with a licensed clinical 
social worker (LCSW) on April 30, 2020. 
 
You asked the Plan to waive the copayment for the visit with a LCSW. You say that you should not have a 
copayment for this service. The Plan denied your request. The Plan says you were charged this copayment 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for outpatient mental health care visits.  
 
You have been asked to pay a $40 copayment for the visit with a LCSW. The visit with a LCSW falls within 
the outpatient mental health care 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 
the visit you had with a licensed clinical social worker (LCSW) on April 30, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic digital breast tomosynthesis coded 77062 
provided. 
 
You asked the Plan to pay for diagnostic digital breast tomosynthesis. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
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 medical record. Specifically, this code has a status code of 
"I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for 
reporting of, and payment of these services. Based on this information, we decided that Medicare rules for 
coverage of diagnostic digital breast tomosynthesis have not been met. Therefore, we decided that the Plan 
does not have to pay for diagnostic digital breast tomosynthesis coded 77062 provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for DME provided on January 16, 2020. 
 
You asked the Plan to pay for the DME. The Plan denied your request. The Plan says the Plan requires 
utilization of network providers when possible and available, and requires authorization for certain services. No 
medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been 
documented. 
 
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 did not pre-approve the 
DME. We found no exception that would require the Plan to pay for these items. Therefore, we decided that the 
Plan does not have to pay for DME provided on January 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran inpatient hospital stay from May 11, 2020, to May 20, 2020.You asked the Plan to waive the copayment foran inpatient hospital stay. You say that you should not be charged for the last three days.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 $265 copayment for days 1-7 forinpatient hospital care. You had an inpatient hospital stay from May 11, 2020, to May 20, 2020. Therefore, you are responsible to pay a $265 copayment for days 1-7 (May 11, 2020, to 17, 2020). However, you are only being asked to pay $1,795, which is less than the total copayment amount. You have been asked to pay $1,795 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital care 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 foran inpatient hospital stay from May 11, 2020, to May 20, 2020.
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 the claim should be paid for a 
wound. The Plan denied your request. The Plan says these stockings are noncovered under the surgical benefit 
as they do not meet the statutory definition of a dressing. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the copayment for the eye exam (92012) and the computerized 
ophthalmic diagnostic imaging service (92134) provided on March 17, 2020. 
 
You asked the Plan to adjust the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the services provided. 
 
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 $50 
copayment for outpatient diagnostic procedures and tests. Additionally, enrollees pay a $40 copayment for each 
specialist in-person office visit.  
 
You have been asked to pay a $87.69 copayment ($40 + $47.69) for the specialist in-person office visit and 
outpatient diagnostic test provided. This amount is less than the applicable combined copayments. 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 adjust the copayment for the eye exam (92012) and the computerized ophthalmic diagnostic 
imaging service (92134) provided on March 17, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from September 22, 
2019, to September 24, 2019. 
 
You asked the Plan to pay for the inpatient hospital services. You say that the enrollee was not enrolled in 
hospice at the time the services were rendered. The Plan denied your request. The Plan says the enrollee's 
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. The Plan also says it is the 
provider's responsibility to verify the member's coverage before rendering services and to know proper billing 
procedures for a Medicare Advantage member on hospice. 
 
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.  
 
While the enrollee had disenrolled in hospice on September 22, 2019, the enrollee was under the Medicare 
hospice benefit for the dates of service at issue in this appeal as coverage goes through the last day of the 
month in which hospice is revoked. Additionally, the record shows that the enrollee re-enrolled in hospice on 
September 24, 2020. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services 
provided from September 22, 2019, to September 24, 2019.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia service provided on October 13, 2019. 
 
You asked the Plan to pay for the anesthesia service. You say that the services were necessary. The Plan denied 
your request. The Plan says the enrollees 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. The Plan also says it is the providers responsibility to verify the members coverage before 
rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on October 12, 2019. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the anesthesia 
service provided on October 13, 2019.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the electrodes, lead wires, unlisted neurological or neuromuscular 
diagnostic procedure, continuous intraoperative neurophysiology monitoring services provided on October 8, 
2019. 
 
You asked the Plan to pay for the electrodes, lead wires, unlisted neurological or neuromuscular diagnostic 
procedure, continuous intraoperative neurophysiology monitoring services. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says that non-participating provider 
billing codes not payable by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Review of the file shows that the case file submitted only 9 pages and was 
largely incomplete. The case file is missing required information including the claim submitted to the plan from 
the provider, the initial authorization request, the plan?s initial denial, and the reconsideration request. 
Therefore, we decided that the Plan has to pay for the electrodes, lead wires, unlisted neurological or 
neuromuscular diagnostic procedure, continuous intraoperative neurophysiology monitoring services provided 
on October 8, 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.