Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee clearly meets criteria for 
LTACH care. The Plan denied your request. The Plan says an LTACH cannot offer any services that is 
superior to those provided at the current facility. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the patient is an 83-year-old who was admitted to the current acute care hospital for 
treatment of hematuria and urinary retention. He was treated with cystourethroscopy, fulguration, and bladder 
irrigation. The course was complicated by testing positive for COVID-19, being diagnosed and treated for 
bilateral DVT, pneumonia/pulmonary edema, and acute metabolic encephalopathy. He is requiring high flow 
oxygen, antibiotics, steroids, Xarelto, nutrition support. The patient recently has been improving. Urology has 
signed off. CXR findings of alveolar opacities appear to be improving. 
 
It is unexpected for the patient to require more than an additional 25 days of acute care services, which can be 
safely completed at the current facility. The patient does not require services at the LTACH that are not already 
available at the current facility. Therefore, this request for LTACH services will be considered not medically 
necessary. Transfer to a lower level of care may be considered soon, when treatment has completed. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long-term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extremity study (93971) and lower extremity study 
(93926) by an out of network (OON) provider. 
 
You asked the Plan to pay for extremity studies. You say that the services rendered were medically necessary. 
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 extremity study (93971) and lower extremity 
study (93926) provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services you received 
from February 4, 2020, to February 14, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that while visiting the 
hospital you fell and fainted.  You say that you were admitted without any discussion and no results from 
testing were found.  You said that you would like this charge waived. 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 $375 
copayment per day for days 1-6 and a $0 copayment per day for days 6-90 for inpatient hospital care.  
 
Records show that you were in the hospital for a total of 10 days.  In accordance with your contract, you were 
charged a $375 copayment per day for the first 5 days and a $0 copayment per day for the remaining 5 days, for 
a total of $1875. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing applies regardless of the reason for the inpatient admission. 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 inpatient hospital services you received from February 4, 2020, 
to February 14, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the MTHFR gene analysis provided on March 2, 2020. 
 
You asked the Plan to pay for the MTHFR gene analysis. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that genetic testing for the MTHFR gene for all risk 
factors, signs, symptoms, diseases, or conditions, including cardiovascular risk assessment, are non-covered 
except for pregnant enrollees. 
 
Review of the file shows that the plan uses LCD L36400 to support their denial. However, LCD L36400 is not 
valid for the non-participating providers billing address state of Georgia. Therefore, we cannot use LCD 
L36400 to substantiate our denial. 
 
We looked at the file and Medicare rules. Review of the file does not support that the enrollee was pregnant 
during this testing. Based on this information, we decided that Medicare rules for coverage of the MTHFR gene 
analysis have not been met. Therefore, we decided that the Plan does not have to pay for the MTHFR gene 
analysis provided on March 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vanos 0.1% cream 
 
You asked the Plan to pre-approve the cream. You say that this is medically necessary. The Plan denied your 
request. The Plan says the medication falls under Part D coverage, but the enrollee has not Part D 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 Vanos 0.1% cream
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services provided on November 3, 2019. 
 
You asked the Plan to pay for the physician services. You say that the service was provided to the enrollee 
prior to being transferred to hospice. 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.  
 
The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the critical care services provided on November 3, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug test (G0481) provided on April 11, 2020, by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the drug test. 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 drug test (G0481) provided on April 11, 2020, 
by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 99000) provided on March 11, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "B" under the Physician Fee 
Schedule indicates that payment for covered services are always bundled into payment for other services not 
specified.  
 
We looked at the file and Medicare rules. Procedure code 99000 is assigned a status indicator of ?B? under the 
Physician Fee Schedule, which means that this is a bundled service. Payment for this service is bundled into 
payment for other services. No separate payment can be made for these services. 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 the services (CPT 99000) provided on March 11, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (CPT 87633) provided on January 23, 2020. 
 
You asked the Plan to pay for the lab services. You say that The Plan denied your request. The Plan says this is 
not a covered service. 
 
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 lab services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee in this case is not immunocompromised or at otherwise increased risk of having 
complications if her symptoms are related to a particular viral etiology to justify a broad viral testing panel. 
Testing would not have changed the treatment if one of the viral etiologies were found in testing. Therefore, 
this request for 87633 (respiratory virus DNA/RNA panel) will be considered not medically necessary for this 
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 the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services (CPT 87633) provided on January 23, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on May 21, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says non-
emergent, 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 
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 May 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for2 retainer crowns (D6241) and a pontic (D6751) provided on May 27, 2020.You asked the Plan to pay forthe dental services. You say that you wonder why you have insurance at all. You say that you ended up needing an extraction. You say that you then had a tooth missing in the front of your mouth. You say that you needed a bridge so that you would not have a toothless smile.The Plan denied your request. The Plan says the retainer crown is not listed as a covered service. The Plan also says that the pontic is not listed as a covered service.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. The Evidence of Coverage clearly states that any services not listed are not covered.Therefore, we decided that the Plan does not have to pay for2 retainer crowns (D6241) and a pontic (D6751) provided on May 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe medical services to be provided by an out-of-network provider with an in-network benefit exception.You asked the Plan to pre-approvethe medical services. You say that you should be able to see the provider in-network.The Plan denied your request. The Plan says there are in-network providers that can treat your condition. The Plan states you can also elect to use your out-of-network benefits to continue to see your doctor at the hospital, if they are willing.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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.A review of the documentation provided, does not demonstrate that in-network specialistproviders within the same geography that can provide this service, have been exhausted. The request for an in-network benefit exception is therefore not approved. The Plan states you can also elect to use your out-of-network benefits to continue to see your doctor at the hospital, if they are willing. 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. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvethe medical services to be provided by an out-of-network provider with an in-network benefit exception.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe full mouth debridement (D4355) provided on June 26, 2020.You asked the Plan to pay forthe dental service. You say that your provider advised that the service was approved. You also say that the service should be covered.The Plan denied your request. The Plan says full mouth debridement cannot be performed on the same day or less than 1 calendar year after an evaluation. The Plan says that the benefit has been exhausted. The Plan also says that eligibility should beconfirmed prior to the actual rendering of services and that the service will only be approved if the enrollee is eligible at the time of service.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceedsMedicare 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 benefit for this service this been exhausted. The Evidence of Coverage clearly states that the service you received cannot be provided within 1 calendar year of an evaluation. The record shows that you received a comprehensive oral evaluation (D0150) on May 14, 2020.Therefore, we decided that the Plan does not have to pay forthe full mouth debridement (D4355) provided on June 26, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zilretta. 
 
You asked the Plan to pre-approve Zilretta. You say that this is medically necessary. The Plan denied your 
request. The Plan says that authorization for repeat administration of Zilretta for either knee cannot be 
provided. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Zilretta. Our reviewer says that Zilretta 
is not medically reasonable and necessary in this case. Documentation notes that you have had Zilretta 
injections in both knees. Review of compendia states that the safety and efficacy of repeat administration has 
not been established. Without the support of the compendia, medical necessity cannot be determined. Our 
physician reviewer found that your condition does not meet criteria for coverage of Zilretta. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Zilretta have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Zilretta.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 Guardant360 testing is not supported in the medical record. Specifically, this service should be 
reported with code 81479. In addition, the appropriate DEX Z code identifier should be entered adjacent to the 
code in the comment/narrative field. Based on this information, we decided that Medicare rules for coverage of 
the Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
Guardant360 testing provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to make a one-time exception and pay for 1 surgical extraction (D7210) 
provided on June 5, 2020. 
 
You asked the Plan to make a one-time exception and pay for the dental service. You say that the enrollee had 
4 teeth extracted on the date of service. You say that only 3 of the extractions were paid. You say that the 
enrollee was not aware that only 3 of the extractions would be covered. You also say that the enrollee does not 
have the means to pay for this service. The Plan denied your request. The Plan says up to 3 surgical extractions 
per calendar year are covered. The Plan says the frequency limit has been exceeded. 
 
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 frequency limit of up to 3 surgical 
extractions per calendar year has been exceeded. The record shows that the Plan paid for 3 surgical extractions 
that you received on the same date of service. The Evidence of Coverage clearly states that up to 3 surgical 
extractions are covered per calendar year. Therefore, we decided that the Plan does not have to make a one-
time exception and pay for 1 surgical extraction (D7210) provided on June 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ophthalmology services provided on March 31, 2020, to 
July 7, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the ophthalmology services. You say that you would like this claim reprocessed 
and approved for payment. 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 ophthalmology services provided on March 
31, 2020, to July 7, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management; 30 minutes or less (CPT 
Code 99238) provided on May 25, 2020. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says CPT code 99238, billed was denied because it was reported with another evaluation and 
management service, 99233 billed on the same day by the same provider under the claim . 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Per review of the submitted documentation, only the inpatient visit is supported as being performed on date of 
service May 25, 2020. Based on this information, we decided that Medicare rules for coverage of the service 
have not been met. Therefore, we decided that the Plan does not have to pay for hospital discharge day 
management; 30 minutes or less (CPT Code 99238) provided on May 25, 2020.