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

 
We decided that the Plan does not have to pay for genetic screening testing provided on January 20, 2020. 
 
You asked the Plan to pay for genetic tests. You say that you are appealing with records to support medical 
necessity. The Plan denied your request. The Plan says the denial of payment for these services is correct, 
because these tests were performed for screening purposes which is not a Medicare benefit. 
 
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 tests at issue in this appeal, genetic tests, were requested for screening purposes. Medicare does not cover 
these tests for screening purposes. Therefore, we decided that the Plan does not have to pay for genetic 
screening testing provided on January 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for orthotics (L1851, L2397, L2385, L2820, L2830, L3960, 
L3916) provided on April 30, 2020. 
 
You asked the Plan to pay for orthotics. You say that these items were medically necessary. The Plan denied 
your request. The Plan says these items were provided following an unsolicited outreach call. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for orthotics (L1851, L2397, 
L2385, L2820, L2830, L3960, L3916) provided on April 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a rest home visit provided on June 11, 2019 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for a rest home visit. You say that these services were provided in a facility. You say 
that is not the providers responsibility to obtained prior authorization. The Plan denied your request. The Plan 
says prior authorization was not obtained. 
 
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 
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 a rest home visit provided on June 11, 2019 by an 
out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care, for evaluation and management of the critically 
ill or critically injured patient; first 30-74 minutes (99291, 25) provided December 2, 2019. 
 
You asked the Plan to pay for the critical care services. You say that the medical records provided should 
support the necessity of the service in dispute. The Plan denied your request. The Plan says there is no 
documentation of critical care time spent to corroborate the services so we can confirm Medicare coverage has 
been met. 
 
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, for evaluation and management of 
the critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical records. We asked our 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 critical care services. Our reviewer says that the documentation submitted was reviewed 
and does not meet criteria. The documentation did not include critical care evaluation and management, as well 
as, time spent during critical care and management.  Therefore, this code cannot be verified if performed. 
 
We looked at the review, the file, and Medicare rules. 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, for evaluation and management of the critically ill or critically injured patient; first 
30-74 minutes (99291, 25) provided December 2, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on December 19, 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 testing at issue in this appeal was 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 19, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient and Part B drug services provided on February 
10, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the outpatient and Part B drug services. You say that the records provided should 
support the necessity of the service in dispute. The Plan denied your request. The Plan says enrollees must 
receive their medical services from an in-network provider. Non-emergent services with non-contracted 
providers require prior-authorization prior to services being rendered. 
 
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 outpatient and Part B drug services provided 
on February 10, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient shoulder surgery. 
 
You asked the Plan to pre-approve shoulder surgery. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
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 shoulder surgery. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there is no documentation of a recent trial and failure of physical therapy. Surgery is not 
needed. More conservative measures are needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of shoulder surgery have not been met. Therefore, we decided that the Plan does 
not have to pre-approve inpatient shoulder surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac (SI) joint injection. 
 
You asked the Plan to pre-approve the SI joint injection. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
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 SI joint injection. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the member did not show a reproduction of pain with Faber test or Gaenslen test, and her 
Waddell signs as well as her femoral stretch were both negative. In addition, imaging did not show SI joint 
disease. The requested SI joint injection 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 SI joint injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a sacroiliac (SI) joint injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bronchial thermoplasty coded as 31660, 31661. 
 
You asked the Plan to pre-approve bronchial thermoplasty. You say that the enrollee has been under your care 
for severe persistent asthma with frequent exacerbations. You believe she will benefit from bronchial 
thermoplasty to decrease frequency of exacerbations. The Plan denied your request. The Plan says bronchial 
thermoplasty is not medically necessary and is not covered as a treatment for any condition, including but not 
limited to asthma. 
 
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 bronchial thermoplasty. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this enrollee has a diagnosis of severe persistent asthma, and remains symptomatic 
despite maximum medical therapy, including Nucala.  However, spirometry has been normal on two occasions, 
in 2018 and 2019.  There is no objective evidence of airways obstruction.  Bronchodilator challenge testing has 
been negative, although it is unclear whether bronchodilators were withheld prior to testing.  There is no 
evidence of air trapping or hyperinflation on chest imaging, and she has never had lung volume testing.  She 
has not had a methacholine challenge test.  There is a history of pneumonia with basilar infiltrates, and a chest 
CT showed a dilated, fluid-filled esophagus, raising the possibility of silent aspiration.  She is apparently also 
suspected of having vocal cord dysfunction, which can masquerade as asthma.  These alternative diagnoses 
need to be explored, and the diagnosis of asthma confirmed by appropriate testing, prior to considering 
bronchial thermoplasty. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bronchial thermoplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bronchial thermoplasty coded as 31660, 31661.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laparoscopy, surgical; with bilateral total pelvic 
lymphadenectomy and peri-aortic lymph node sampling, peritoneal washings, peritoneal biopsy(ies), 
omentectomy, and diaphragmatic washings, including diaphragmatic and other serosal biopsy(ies), when 
performed (CPT Code 38573) provided on February 13, 2020. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records. 
 
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 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 physician reviewer found 
the services (CPT Code 38573) are not supported in the medical records received. The operative report 
supports the use of CPT 38571 (Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy)  
 
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 laparoscopy, surgical; with bilateral total pelvic lymphadenectomy and peri-aortic lymph node 
sampling, peritoneal washings, peritoneal biopsy(ies), omentectomy, and diaphragmatic washings, including 
diaphragmatic and other serosal biopsy(ies), when performed (CPT Code 38573) provided on February 13, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing x-ray provided on February 4, 2020 by an OON 
provider. 
 
You asked the Plan to pay for the bitewing x-ray. You say that the enrollee received an annual notice of 
changes that does not say anything about confirming that the enrollee's dentist is still in-network. You also say 
that the enrollee did not receive any information on what dentists are in network, and assumed the Plan would 
cover the enrollee. The Plan denied your request. The Plan says these services were rendered by an OON 
provider. The Plan also says that services done by an OON dentist are not covered. 
 
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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the 
bitewing x-ray provided on February 4, 2020 by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Positron Emission Tomography (PET) imaging (78815) 
performed December 12, 2019. 
 
You asked the Plan to pay for the PET scan. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the claim did not include a valid diagnosis code. 
 
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 78815 is not supported in the medical record. Specifically, C34.92 - Malignant 
neoplasm of unspecified part of left bronchus or lung, is not listed as a valid diagnosis code for this CPT code. 
Based on this information, we decided that Medicare rules for coverage of the PET scan have not been met. 
Therefore, we decided that the Plan does not have to pay for Positron Emission Tomography (PET) imaging 
(78815) performed December 12, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided February 16, 2020 
to February 17, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that inpatient care was medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found care provided to the enrollee was observation level. There were no advance 
interventions or complex medical conditions. The enrollee had stable vital signs and no complaints at the time 
of admission. Inpatient care services were not supported by the documentation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided February 16, 2020 to February 17, 
2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CPT code 77062 provided on January 29, 2020. 
 
You asked the Plan to pay for CPT code 77062. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. In this case, CPT code 77062 has a status code of "I" under the 
Medicare Physicians Fee Schedule Database (MPFSDB) and is not valid for Medicare purposes. Medicare uses 
another code for reporting of, and payment for, this service. Therefore, we decided that the Plan does not have 
to pay for CPT code 77062 provided on January 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of residual tooth roots (D7250), first 15 minutes 
of deep sedation/general anesthesia (D9222), and each subsequent 15 minute increment of deep 
sedation/general anesthesia (D9223) provided on February 4, 2020. 
 
You asked the Plan to pay for the removal of residual tooth roots and deep sedation/general anesthesia services. 
You say that pages 4-90 and 4-91 show that these codes are covered at 50%. The Plan denied your request. The 
Plan says these services are not covered benefits. The Plan also says that you were not enrolled in the 
supplemental dental program in February 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 
removal of residual tooth roots (D7250), first 15 minutes of deep sedation/general anesthesia (D9222), and 
each subsequent 15 minute increment of deep sedation/general anesthesia (D9223) provided on February 4, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on December 18, 2019. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says it is 
important to know which providers are part of our network because, with limited exceptions, while you are a 
member of our plan you must use network providers to get your medical care and 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 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 physician's services provided on December 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewings, periodic oral evaluation, and prophylaxis 
provided on January 8, 2020 by an OON provider. 
 
You asked the Plan to pay for the bitewings, periodic oral evaluation, and prophylaxis. You say that because 
you are allowed up to $1,000 on your dental, you believed you would be completely covered. You also say that 
the Plan documentation says you can use out-of-network dentists. The Plan denied your request. The Plan says 
these services were rendered by an OON provider. The Plan also says that the charges exceed the allowable 
amounts, and you may still be billed by an OON provider for any amount greater than the MAC payment made 
by the Plan to the provider. 
 
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 are responsible for the difference 
between the billed amount and allowed amount. Therefore, we decided that the Plan does not have to pay for 
the bitewings, periodic oral evaluation, and prophylaxis provided on January 8, 2020 by an OON provider.  
 
Your complaint about your issues with the in-network provider, and being misled by the Plan's documentation 
is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by 
the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on March 3, 2020. 
 
You asked the Plan to pay for the laboratory services. 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 
laboratory services. 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 laboratory services provided on March 3, 2020.