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

 
We decided that the Plan has to pay for the FoundationOne CDx (F1CDx) testing provided on February 24, 
2022. 
 
You asked the Plan to pay for the F1CDx testing. You say that this is an FDA-approved test that is covered by 
Medicare. The Plan denied your request. The Plan says that the services provided are not a covered benefit. 
 
We reviewed the LCDs cited by the Plan but find that it is not applicable to an FDA-approved test, as these are 
covered via the NCD cited in the Medicare rules section. An LCD cannot limit coverage allowed by an NCD, 
per the Medicare hierarchy of authority. In addition, the one LCD used by the Plan is not valid for the 
providers head quarter billing state of Pennsylvania. As such, we disregarded the LCDs cited by the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, such as the F1CDx panel, when provided for an FDA-approved indication. We looked at the file and 
Medicare rules. This testing was provided to a patient with a solid tumor. The FDA approval notice indicates 
that this panel is approved for solid tumors. No other valid denial rationale was presented by the Plan. 
Therefore, we decided that the Plan has to pay for the FoundationOne CDx (F1CDx) testing provided on 
February 24, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you have been in several nursing facilities and 
nothing has worked. You say that you feel that you need to be in an inpatient rehabilitation facility. The Plan 
denied your request. The Plan says admission to IRF was denied as not meeting criteria, is not medically 
necessary, and a lower level of care might be appropriate. Skilled nursing facility level of care was offered. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  
 Our physician reviewer found there are no complex nursing or rehabilitation needs. While you have a need for 
physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One. 
 
You asked the Plan to pre-approve Gel-One. You say that you have had an appropriate trial and failure of other 
conservative interventions. You say that Gel-One is medically necessary and supported by the records 
provided. The Plan denied your request. The Plan says there is no known documented trial of, or 
contraindication to, the preferred products. 
 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 
criteria for coverage have not been met. Our physician reviewer found the Plan requires a trial of Synvisc, 
Durolane, and Gelsyn-3 before they will approve the requested drug. The record indicates that you have 
osteoarthritis of the knee.  The requested medication is a new start.  The provided records do not indicate that 
you have tried and failed the Plan's preferred step one alternative. The record does not indicate that you have a 
contraindication to or would have an adverse effect from the Plan's preferred step one alternative. 
 
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.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayment for telehealth visit provided on March 4, 2022. 
 
You asked the Plan to waive the copayment for telehealth visit. You say that this visit should be covered. The 
Plan denied your request. The Plan says that the copayment applied is correct. 
 
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 does not say in clear and accurate 
terms how much you should expect to pay for telehealth visits.  
 
We looked at your contract with the Plan. We did not see where the contract says enrollees must pay $40 
copayment for telehealth visits. The Plan contract does not clarify when enrollees should expect to pay $0 or 
$40 copayment for telehealth visits. This means that the Plan did not follow Medicare rules for disclosure of 
cost sharing information. Therefore, we decided that the Plan has to waive the copayment for telehealth visit 
provided on March 4, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on May 23, 2022. 
 
You asked the Plan to pay for the domiciliary or rest home visit. The Plan denied your request. The Plan says 
services from non-participating providers are not covered unless preauthorized 
 
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 a domiciliary or rest home visit provided on May 23, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital outpatient services provided on April 21, 2021. 
 
You asked the Plan to pay for the services provided. You say that the codes billed are correct. The Plan denied 
your request. The Plan says a device code was not reported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT code 19281 is a device procedure. The claim does not show that a device code was reported 
for the same date of service. Based on this information, we decided that Medicare rules for coverage of the 
services provided have not been met. Therefore, we decided that the Plan does not have to pay for the hospital 
outpatient services provided on April 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on March 25, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that these services were a medical necessity. The 
Plan denied your request. The Plan says the service obtained by the member was rendered by a provider 
who is not under contract with the Plan. 
 
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 had network providers 
available who could have provided 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 laboratory services provided on March 25, 2022, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 28, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the services were performed by the request 
of the ordering physician, and you would like reimbursement for the services rendered. The Plan denied your 
request. The Plan says the rendering and referring providers are both OON providers and there was no 
approved 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 had network providers 
available who could have provided 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 laboratory services provided on March 28, 
2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve self-administered drugs received from March 30, 2022, 
to March 31, 2022. 
 
You asked the Plan to pre-approve the drugs. You say that this is medically necessary. The Plan denied your 
request. The Plan says this request cannot be approved. 
 
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 self-administered drugs 
received from March 30, 2022, to March 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care services provided on May 5, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for wound care services. You say that the services provided were medically 
necessary. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 had network providers 
available who could have provided 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 wound care services provided on May 5, 2022, by 
an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid (V5253) provided on April 26, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the hearing aids. You say that based on your coverage information, you would 
like to be reimbursed $2,500 of the $4,400 for the hearing aid charge. The Plan denied your request. The Plan 
says you did not utilize your hearing aid benefit, and did not use a Plan approved hearing provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when you use the Plan's hearing aid vendor.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for 
the hearing aid (V5253) provided on April 26, 2022, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99601 and 99602 billed for date of service 
March 3, 2022, to March 4, 2022. 
 
You asked the Plan to pay for procedure codes 99601 and 99602. You say that you would like this claim 
reprocessed based on the medical records. The Plan denied your request. The Plan says the billed codes are 
invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99601 and 99602 both have a Status Indicator of I on the Physician Fee Schedule. This means that procedure codes 99601 and 99602 are both not valid for Medicare purposes. Based on this 
information, we decided that Medicare rules for coverage of procedure codes 99601 and 99602 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 99601 and 99602 billed for 
date of service March 3, 2022, to March 4, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says step-therapy rules for the requested drug have 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 Prolia. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires a history of an osteoporotic fracture or a trial of zoledronic acid before they will approve the 
requested drug, Prolia. The available records do not report a history of an osteoporotic fracture. There is no 
indication that the enrollee has tried and failed the required drug. Based on the medical records provided and 
the Medicare-approved major drug compendia, there is no indication that the Plan's required drug 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Prolia (J0897).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a limited oral evaluation (D0140), a periapical x-ray 
(D0220), and extractions of tooth #2 and 3 (D7140) provided on May 20, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you do not agree with the reimbursement 
amount you received. The Plan denied your request. The Plan says you are responsible for any charged amount 
above the Plans cost-sharing amount when your services are received from an out-of-network provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for a limited oral evaluation (D0140), a 
periapical x-ray (D0220), and extractions of tooth #2 and 3 (D7140) provided on May 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88341 and 88342 billed for date of service 
October 18, 2021. 
 You asked the Plan to pay for procedure code 88341 and 88342. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says payment for code 88341 
and 88342 is bundled into payment for code 88360. 
 
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, we have confirmed that codes 
88341 and 88342 are column II codes to column I code 88360. This claim has not been billed with an 
appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 88341 and 88342 billed for 
date of service October 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an at-home COVID-19 test purchased on January 19, 2022. 
 
You asked the Plan to pay for an at-home COVID-19 test. You say that the Plan did not tell you that you had to 
buy your COVID-19 test from a special place. The Plan denied your request. The Plan says COVID-19 home 
test kits are not eligible benefits or for reimbursement through the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say they will cover up to eight over-the-counter COVID-
19 tests each calendar month at no cost to you. Medicare rules also say that you can get over-the-counter 
COVID-19 tests at any pharmacy or health care provider that participates in this initiative.  
  We looked at the file and Medicare rules. COVID-19 home test kids are not eligible for reimbursement through 
the Plan. Specifically, this particular test is not covered because it was provided before April 4, 2022. Based on 
this information, we decided that Medicare rules for coverage of an at-home COVID-19 test have not been met. 
Therefore, we decided that the Plan does not have to pay for an at-home COVID-19 test purchased on January 
19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for alveoloplasty (D7311), and deep sedation/general anesthesia 
(D9223) provided on May 20, 2022. 
 
You asked the Plan to pay for alveoloplasty, and deep sedation/general anesthesia. You say that you want the 
Plan to pay for these services. The Plan denied your request. The Plan says the services at issue are not covered 
benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 
alveoloplasty (D7311), and deep sedation/general anesthesia (D9223) provided on May 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 49002-58-59 billed for date of service 
November 28, 2021. 
 
You asked the Plan to pay for procedure code 49002-58-59. You say that this code was denied incorrectly 
because the -59 modifier was appended. The Plan denied your request. The Plan says code 49002-58-59 is not 
supported in the medical record and is inclusive to 44160-58. (All other billed codes have been paid.) 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 procedure code 49002-58-59 Our reviewer 
says that procedure code 49002-58-59 is not supported in the medical record. Our physician reviewer found the 
records do not support that this code is separate and distinct from code 44160.  The entire reason for the 
revision service is related to code 44160, so separate payment of 49002-58-59 is not warranted. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of procedure code 49002-58-59 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 49002-58-59 billed for date of service November 28, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic colonoscopy provided on April 
12, 2022. 
 
You asked the Plan to waive the copayment for diagnostic colonoscopy. You say that you were told the 
procedure would be covered. The Plan denied your request. The Plan says the copayment applied is correct. 
 
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 $245 
copayment for a diagnostic colonoscopy preformed in an ambulatory surgical center.  
 
You have been asked to pay $245 copayment for diagnostic colonoscopy. Diagnostic colonoscopys fall 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 diagnostic colonoscopy provided on April 12, 2022.