Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on
December 6, 2019.
You asked the Plan to pay for the knee orthosis (L1851) and suspension sleeve (L2397). You say that the
orthoses were medically necessary. The Plan denied your request. The Plan says there is no evidence of an
established relationship between the enrollee and the ordering physician.
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 knee orthosis (L1851) and suspension
sleeve (L2397). Our reviewer says that the orthoses are not medically necessary. Our physician reviewer found
the enrollee's chief complaint was chronic pain, knee right. The documentation in the case file does not support
that the requested knee orthosis and sleeve were medically reasonable and necessary for the enrollee in this
case, according to the coverage criteria established by the LCD. There is no documentation of recent injury to,
or recent surgical procedure on, the enrollee's knee, and there is insufficient credible objective documentation
of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered.
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 knee orthosis (L1851) and suspension sleeve (L2397) have not been met.
Therefore, we decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided
on December 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-ofnetwork
provider on December 7, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.
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 7, 2019.
Appeal type: Practitioner Services
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 9, 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 9, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on July 8, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that the person who drove you to urgent care was not notified you were transferred to the hospital. You say that you were not informed that there was an ambulance waiver you could have signed. The Plan denied your request. The Plan says the copayment applied 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 $200 copayment for each one-way Medicare-covered ground trip. You have been asked to pay a $200 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance 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 ambulance transport provided on July 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician's services provided on September 23, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says nonemergent,
non-urgent services with out-of-network providers require prior authorization.
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 the physician's services provided on September 23, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a kidney transplant for the enrollee.
You asked the Plan to pre-approve the transplant. You say that this is medically necessary. The Plan denied
your request. The Plan says significant/daily marijuana use is an absolute contraindication for a complex posttransplant
plan of care, because it increases the risk for non-adherence and increased morbidity and mortality.
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 transplant. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the documentation does not support that a kidney transplant is medically reasonable and
necessary for the enrollee in this case. Active abuse of drugs, alcohol, or other substances is a contraindication
to kidney transplantation. Substance abuse dates back to age 62. A drug screen was positive for cannabinoids
on 9/24/19. On 5/5/20, 11 Hydroxy delta 9 THC, Delta 9 corboxy THC, and Delta 9 THC were detected.
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 transplant have not been met. Therefore, we decided that the Plan does not
have to pre-approve a kidney transplant for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous left atrial appendage closure (LAAC).
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan
denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that LAAC is covered when specific criteria are met.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has permanent atrial
fibrillation and is tolerating long term anticoagulation without side effects. The criteria for coverage of the
LAAC are not met, as the records do not show that the enrollee is unable to safely continue long-term
anticoagulation. The documentation does not include a formal shared decision making process using an
evidence based decision tool by an independent non-interventional physician. The services are not reasonable
or medically necessary 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 percutaneous left atrial appendage closure (LAAC).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound provided on December 23,
2019.
You asked the Plan to waive the copayment for the ultrasound. You say that if you had known the ultrasound
would cost this much, you would not have had the procedure done. 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 $100
copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a
physician's office or at a free-standing facility. For this date of service, you have been asked to pay the allowed
amount of the claim because this amount is less than the $100 copayment for the ultrasound.
You have been asked to pay a $97.44 copayment for the ultrasound. The ultrasound falls within the "Outpatient
Diagnostic Tests and Therapeutic Services and Supplies" benefit category. This means that you have been
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have
to waive the copayment for the ultrasound provided on December 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the excision of a benign lesion (D7410)
provided on January 24, 2020.
You asked the Plan to issue reimbursement for this service. You say that you are requesting a reconsideration
of the Plan's denial for payment. The Plan denied your request. The Plan says this service is not a covered
benefit under the member's contractual policy.
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 service provided is not among
those covered under this benefit. Therefore, we decided that the Plan does not have to issue reimbursement for
the excision of a benign lesion (D7410) provided on January 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the immediate maxillary denture provided on November 21,
2019.
You asked the Plan to pay for the immediate maxillary denture. You say that the provider did not seek approval
of the immediate maxillary denture. The Plan denied your request. The Plan says your $2,500 benefit
maximum was met prior to the processing of this claim.
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 Plan offers a $2,500 annual dental
benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are
responsible for the full charges of any additional dental services. The record shows that you met the annual
maximum benefit on November 15, 2019 and your annual maximum benefit was then exhausted. Therefore, we
decided that the Plan does not have to pay for the immediate maxillary denture provided on November 21,
2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on December 2, 2019.
You asked the Plan to waive the copayment for the colonoscopy. You say that the colonoscopy is a preventive covered service. The Plan denied your request. The Plan says the copayment applied 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 $210 copayment for surgical services at an in-network ambulatory surgical center. You have been asked to pay a $210 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that the colonoscopy was ordered due to constipation and bleeding, which is considered a diagnostic colonoscopy. 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 colonoscopy provided on December 2, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses and suspension sleeves provided on
December 27, 2019.
You asked the Plan to pay for the knee orthoses (L1833) and suspension sleeves (L2397). You say that the Plan
should pay this claim. The Plan denied your request. The Plan says the documentation submitted did not
indicate the provider discussed the need for the billed supply codes, therefore the billed supply codes cannot be
verified.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the file and Medicare rules. The medical records do not mention or support medical necessity for
the orthoses Based on this information, we decided that Medicare rules for coverage of the knee orthoses
(L1833) and suspension sleeves (L2397) have not been met. Therefore, we decided that the Plan does not have
to pay for the knee orthoses and suspension sleeves provided on December 27, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for Injection Insulin (J1815).
You asked the Plan to pay for the Insulin. You say that the insulin should be covered. The Plan denied your request. The Plan says because it is self-administered, coverage for the insulin is not available under the Part B medical benefit.
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 pay for Injection Insulin (J1815).
Benefits for the Insulin 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 the medical services provided on June 3, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were rendered by an out-of-network provider without prior authorization.
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 medical services provided on June 3, 2019 by
an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on August 30, 2019.
You asked the Plan to pay for the genetic testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are 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 pay for the genetic testing. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a diagnosis of Malignant neoplasm of tongue, unspecified. A partial glossectomy and neck dissection were performed. Surgical pathology of the right side of the tongue revealed invasive moderately to poorly differentiated squamous cell carcinoma. No additional clinical information is available in the case file. The documentation does not support that the FoundationOne CDx genomic testing was medically reasonable and necessary for the enrollee in this case. Review of the file shows that the plan used Local Coverage Article (LCA), A56853 to support their denial. However, this LCA is not valid for the provider's state of PA. Therefore, we cannot use LCA A56853 to substantiate our decision. 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 genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on August 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided from December 19, 2019 to December 27,
2019, by a chiropractor.
You asked the Plan to pay for the services provided. You say that you need chiropractic care due to
degenerative disc issues. The Plan denied your request. The Plan says the services are not covered by
Medicare.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
The file shows that you received manual therapy, therapeutic exercises, and application of hot or cold packs.
The records show that the services at issue are not manual manipulation of the spine. Services other than
manual manipulation of the spine to correct subluxation, when performed by a chiropractor, are not covered.
Therefore, we decided that the Plan does not have to pay for services provided from December 19, 2019 to
December 27, 2019, by a chiropractor.
Appeal type: Step-Therapy
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 medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 medication is not medically necessary. Our physician reviewer found the provided medical records do not indicate that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gel-one have not been met. Therefore, we decided that the Plan does not have to pre-approve Gel-one (J7326).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a laparoscopy (49320) provided on November 25, 2019.
You asked the Plan to pay for the laparoscopy. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says surgical laparoscopy always includes
diagnostic laparoscopy and incidental examination of other areas shall not be reported separately.
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 coder 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 laparoscopy. Our reviewer says that CPT code 49320
does not meet criteria for billing or reimbursement consideration. Our reviewer found when CPT 49320 is
performed during the same operative session as CCPT 44180 - Laparoscopy, surgical, enterolysis (freeing of
intestinal adhesion) (separate procedure), it is not separately reimbursable. CPT 49320 was submitted to the
health plan with a 59 modifier to unbundle the relationship with 44180, however the NNCI Modifier Crosswalk
does not allow for the use of modifier 59 on 49320 when performed with CPT 44180.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the laparoscopy have not been met. Therefore, we decided that the Plan does
not have to pay for a laparoscopy (49320) provided on November 25, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Duexis.
You asked the Plan to pre-approve Duexis. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit.
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 Duexis.
Benefits for Duexis may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.