Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the screening of retinal photos (S9986) and the eyewear 
protection plan purchased on December 10, 2021. 
 
You asked the Plan to pay for the retinal photos and protection plan. You say that you expected your benefit to 
cover more, and you feel the Plan should reimburse you for the cost of these services. You feel you have been 
misled by the provider. The Plan denied your request. The Plan says these services are not covered by 
Medicare or by your supplemental benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers routine eye exams including refraction and dilation and one set of eyewear 
(eyeglasses and pair of lenses or contact lenses) per calendar year. 
 
We looked at the file and the Plan's rules. Although the Plan offers a supplemental vision benefit in excess of 
Medicare coverage, the screening of retinal photos and eyewear protection plan are not among those 
services/items covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
screening of retinal photos (S9986) and the eyewear protection plan purchased on December 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DermTech Pigmented Lesion Assay (PLA) testing 
rendered on September 10, 2021. 
 
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 not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PLA testing 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 pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee has a personal history of 
malignant melanoma on his right mid medial upper back in 2017, and a history of moderate atypia located on 
his left mid central upper back in 2017. The melanoma was surgically removed. On September 10, 2021 it is 
documented that the enrollee had nevi scattered throughout his body. The documentation does not support that 
the enrollee had a lesion between 5mm and 19mm which met one or more of the ABCDE criteria. The 
documentation is insufficient to support that it was medically reasonable and necessary for the enrollee in this 
case to have the DermTech PLA.  
 
 
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 pay for the DermTech Pigmented Lesion Assay (PLA) testing rendered on September 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on March 31, 2021. 
 
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 are not covered. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the laboratory services rendered on March 31, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode 
array, epidural (CPT code 63650). 
 
You asked the Plan to pre-approve the service. You say that the procedure for insertion of a spinal cord 
stimulator implant is needed. The Plan denied your request. The Plan says the enrollee's records do not show a 
diagnosis for which a spinal cord stimulator would be covered, and they do not support that this is 
recommended only as a late resort for control of the enrollee's pain. 
 
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 service. Our physician reviewer 
found the enrollee does not have an evidence-based indication for a spinal cord stimulator (SCS) trial and there 
other evidence-based modalities that are available to the enrollee. The request 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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous implantation of neurostimulator electrode array, epidural (CPT code 63650).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pradaxa. 
 
You asked the Plan to pre-approve Pradaxa. You say that this drug is medically necessary for the patient. The 
Plan denied your request. The Plan says this self-administered drug is not covered under the patient's medical 
benefits. 
 
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 Pradaxa.  
 
Benefits for Pradaxa 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not qualify for SNF 
coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have 
documented skilled therapy needs. The enrollee is ambulating more than 100 feet. Daily skilled services are not 
shown to be required to establish a maintenance program or to prevent deterioration of the enrollees condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for psychotherapy services provided from November 4, 2021, through 
November 18, 2021. 
 
You asked the Plan to pay for psychotherapy services. The Plan denied your request. The Plan says that the 
provider must attempt to consult the attending or primary care physician about the services furnished and 
document the consent or declination date to consultations, and the date of consultations in the patients medical 
record. There was no documentation of contact in the patient record. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has based their denial rationale on rules that apply to 
Clinical Psychologists. This service was rendered and billed by a Nurse Practitioner. The rules regarding a 
referral or consultation with the enrollees primary care or attending physician do not apply to Nurse 
Practitioners. The Plan has not forwarded any additional documentation to support why the services at issue are 
not payable. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, the Plans 
denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay 
for psychotherapy services provided from November 4, 2021, through November 18, 2021.  
 
 
 
 
 
 
 
 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy sessions provided from November 9, 2021, 
through November 30, 2021. 
 
You asked the Plan to pay for psychotherapy sessions. You say that you have been going to therapy with this 
provider for a few months and she told you that she accepts your health insurance and you have been paying 
your specialty copay of $35 all along. The Plan denied your request. The Plan says the Plan contract states that 
services that you get from non-affiliated providers except for care for a medical emergency and urgently 
needed care, renal (kidney) dialysis services that you get when you are temporarily outside the Plans service 
area, and care from non-affiliated providers that is arranged or approved by the Plans Medical Director are 
excluded from coverage.  
 
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 psychotherapy sessions provided from November 9, 2021, 
through November 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient visit provided on October 15, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for outpatient visit. You say that it isn't your responsibility to get a referral. The Plan 
denied your request. The Plan says prior authorization is required for an out-of-network office 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 outpatient visit provided on October 15, 2021 by 
an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 that at the current level of function, the enrollee's rehabilitation can be safely 
provided at a lower intensity and alternate setting such as in a skilled nursing facility or in-home with services. 
Documentation does not support the necessity for admission to an IRF. 
 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided to the enrollee on May 18, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says Medicare billing criteria were not met. We overturned the Plans denial. The Plan
requested a reopen and provided documentation to show that only 18 drug cases were tested.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate codes. In this case, the records
provided do not support the services listed on the claim. Medicare rules for coverage of this testing have not
been met. Therefore, we decided that the Plan does not have to pay for drug testing provided to the enrollee on
May 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a magnetic resonance imaging (MRI) scan 
provided on November 5, 2021. 
 
You asked the Plan to waive the coinsurance for the MRI scan. You say that you were told that this service 
would be covered in full. The Plan denied your request. The Plan says the proper coinsurance was applied 
 
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 20% 
coinsurance for each Medicare-covered diagnostic radiology. The total amount allowed was $251.45 with a 
coinsurance of $50.29 ($251.45 total amount x 20% coinsurance). 
 
  You have been asked to pay a $50.29 coinsurance for the MRI scan. The MRI scan 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 
coinsurance for a magnetic resonance imaging (MRI) scan provided on November 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on November 4, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the treating provider sent the specimen to 
your laboratory for testing, and you have no control over getting an authorization. The Plan denied your 
request. The Plan says the rendering and referring providers are both out-of-network providers and there was 
no approved authorization. Also, the service rendered was not urgent or emergent. 
 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 November 4, 
2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee can be treated at a lower level of care. 
 
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 the patient does not require treatment by multiple therapies and an intensive 
rehabilitation therapy program. While the patient has a need for physical or occupational therapy, there is no 
documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that this 
patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for post cataract laser surgery provided on June 
23, 2021. 
 
You asked the Plan to waive the copayment for post cataract laser surgery. You say that you feel these charges 
should be covered. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. The Plan also says that the out of network claim was processed at the in-network rate. 
 
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 $395 
copayment for in-network outpatient surgery at an outpatient hospital.  
 You have been asked to pay the allowed amount of $256.41, which is less than the $395 copayment for post 
cataract laser surgery. Post cataract laser surgery falls within the Outpatient Surgery and Other Medical 
Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 post cataract laser surgery provided on June 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on June 11, 2021. 
 
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 procedure code 23430 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 23430 (repair of biceps tendon) and 23472 (reconstruction 
of shoulder joint). Code 23430 is a column II code with a modifier indicator of 1 when billed with column I 
code 23472. Code 23430 was not billed with an appropriate modifier to allow for separate payment. The file 
does not support the billing of the -59 modifier as a separate and distinct procedural service. Therefore, we 
decided that the Plan does not have to pay for the surgical services rendered on June 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99214) provided on April 23, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the patient went to the facility for pre-operative 
service, and had no choice of which provider treated him, and it is usually the responsibility of the facility to 
obtain the authorization. The Plan denied your request. The Plan says this provider is not a network provider 
with the Plan, and they have also determined that these services are not urgent or emergent, nor were they 
approved in advance. 
 
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 an office visit (99214) provided on April 23, 2021, 
by an out-of-network (OON) provider.