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

 
We decided that the Plan does not have to pre-approve treatment with Gamunex (J1561). 
 
You asked the Plan to pre-approve Gamunex. You say that Gamunex is a medical necessity for the enrollee. 
The Plan denied your request. The Plan says Gamunex has been prescribed for an off-label, not medically 
accepted use. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Gamunex. Our reviewer says that 
treatment with Gamunex is not medically reasonable and necessary in this case. Our physician reviewer found 
that the requested use of Gamunex is not FDA-approved for the enrollee's diagnosis. The use is not supported 
by one of the major drug compendia or by clinical research that appears in a Medicare-approved medical 
journal.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gamunex have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Gamunex (J1561).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on August 31, 
2022. 
 
You asked the Plan to pay for the DecisionDx-SCC test. You say that this testing is medically necessary. The 
Plan denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as not covered. Based on this information, we decided that Medicare rules for coverage of the DecisionDx-SCC test have not been met. 
Therefore, we decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on 
August 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crowns (D6740) for tooth #3 and #5 and a 
pontic (D6245) for tooth #4. 
 
You asked the Plan to pre-approve the dental service. You say that the bridge is medically necessary. The Plan 
denied your request. The Plan says the teeth do not show cavities under the previous bridge; therefore, a new 
bridge is not medically necessary. 
 
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. The Plan covers the dental 
service when the services are medically necessary and reasonable.  
 
  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 dental service. Our reviewer says 
that the requested treatment is not medically necessary. Our physician reviewer found that the existing bridge 
from tooth #3 to tooth #5 appears to be intact with no recurrent decay noted around the margins of the crowns. 
Given there is no rationale for replacing what appears to be a serviceable bridge, the request for a replacement 
bridge is not considered medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental service have not been met. Therefore, we decided that the Plan does 
not have to pre-approve retainer crowns (D6740) for tooth #3 and #5 and a pontic (D6245) for tooth #4.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (0239U) provided on October 31, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the out-of-network services were not pre-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 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 lab services (0239U) provided on October 31, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0003A billed for date of service June 17, 
2022. 
 
You asked the Plan to pay for procedure code 0003A. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 0003A is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 0003A have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 0003A billed for date of service June 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crowns for teeth number 6 and 8 (D6740 x 2) 
and a porcelain/ceramic pontic for tooth number 7 (D6245). 
 
You asked the Plan to pre-approve these dental items. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested items are not covered under your 
supplemental dental policy. 
 
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 are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve retainer 
crowns for teeth number 6 and 8 (D6740 x 2) and a porcelain/ceramic pontic for tooth number 7 (D6245).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus laboratory testing billed with codes 81206, 
81210, 81235, 81272, 81275, 81276, 81192, 81295, 81298, 81301, 81311, 81317, 81321, 81194, and 81309 
provided on March 17, 2022. 
 
You asked the Plan to pay for the Tempus laboratory testing. You say that this test should be covered. The Plan 
denied your request. The Plan says this test should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a singled panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the Tempus laboratory testing have not been met. Therefore, we decided that the Plan does not have to pay for the Tempus laboratory testing billed 
with codes 81206, 81210, 81235, 81272, 81275, 81276, 81192, 81295, 81298, 81301, 81311, 81317, 81321, 
81194, and 81309 provided on March 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and related services provided on July 26, 2022. 
 
You asked the Plan to pay for an office visit and related services. You say that this is supported in the records. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit and 
related services provided on July 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the follow-up visits and ophthalmoscopy to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the follow-up visits and ophthalmoscopy. You say that the network provider 
is not experienced with the lens. The Plan denied your request. The Plan says the provider is out-of-network. 
 
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. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the follow-up visits and ophthalmoscopy. We found no exception that would require 
the Plan to pre-approve the follow-up visits and ophthalmoscopy.  Therefore, we decided that the Plan does not have to pre-approve the follow-up visits and ophthalmoscopy to 
be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the injectafer (J1439). 
 You asked the Plan to pre-approve the injectafer. You say that the drug is medically necessary. The Plan denied 
your request. The Plan says the member has not met the step therapy requirements for this drug. 
 
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 the injectafer. Our reviewer says that 
the drug is not medically necessary. Our physician reviewer found the provided records do not indicate that the 
enrollee has tried and failed the plan's preferred step one alternative or that the enrollee has 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 the injectafer have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the injectafer (J1439)..
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99239 provided on November 14, 2022. 
 
You asked the Plan to pay for code 99239. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on December 7, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for code 99239 have not been met. Therefore, 
we decided that the Plan does not have to pay for code 99239 provided on November 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography (CT) of brain without contrast 
material (70450) provided on December 5, 2022. 
 
You asked the Plan to pay for the CT. You say that this procedure is a covered benefit when performed in this 
place of service. The Plan denied your request. The Plan says the wrong place of service was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that as a general policy, the Place of Service (POS) 
code assigned by the physician/practitioner for the professional component (PC) of a diagnostic service shall be 
the setting in which the enrollee received the technical component (TC) service.  
 
We looked at the file and Medicare rules. The claim reflects the 2-digit place of service (POS) code 22 for on 
campus-outpatient hospital. The member was registered as an inpatient of a hospital during the time of service. 
The appropriate inpatient POS code must be used. Based on this information, we decided that Medicare rules for coverage of the CT have not been met. Therefore, we decided that the Plan does not have to pay for a 
computed tomography (CT) of brain without contrast material (70450) provided on December 5, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 93971-TC-LT billed for date of service 
October 29, 2022. 
 
You asked the Plan to pay for procedure code(s) 93971-TC-LT. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says this code is included in the skilled nursing facility 
payment and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the SNF for its Part A inpatients and are not separately payable. 
 
The records indicate that this service was provided to the enrollee while a SNF inpatient. Per the Physician Fee 
Schedule, CPT code 93971-TC-LT has a Professional/Technical indicator of 1. This means that CPT code 
93971-TC-LT has both a professional and technical component. In this case, CPT code 93971-TC-LT has not 
been billed with an appropriate modifier to indicate the professional component. Based on this information, we 
decided that Medicare rules for coverage of procedure code 93971-TC-LT have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) 93971-TC-LT billed for date of service 
October 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 25, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on June 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the intraoral radiographic image (D0230), a cone beam 
(D0364), and a tooth vitality test (D0460) provided on January 2, 2023. 
 
You asked the Plan to pay more for the dental services. You say that the denial for the maximum being met is a 
mistake because your new coverage became effective on January 1, 2023. The Plan denied your request. The 
Plan says your maximum dental benefit for the year has already been exhausted. 
 
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, certain limitations apply. The record 
shows the Plan paid $1,500 for dental services on January 2, 2023; therefore, your benefit for the year of 2023 
was exhausted on the date of service of January 2, 2023. Therefore, we decided that the Plan does not have to 
pay more for the intraoral radiographic image (D0230), a cone beam (D0364), and a tooth vitality test (D0460) 
provided on January 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite - two surfaces, posterior (D2392) 
provided on December 12, 2022. 
 
You asked the Plan to pay for the resin-based composite - two surfaces, posterior. You say that you are not 
disputing the services received but the cost share for the dental services. You also are asking the Plan to 
reconsider paying for the resin as part of your Plan's dental benefits. The Plan denied your request. The Plan 
says this service is not covered under the benefit package. 
 
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 a resin-
based composite - two surfaces, posterior (D2392) provided on December 12, 2022.
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 IRF care will be more suitable than a skilled nursing 
facility to regain maximum function. The Plan denied your request. The Plan says you do not meet the 
Medicare criteria for admission to an IRF. 
 
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 the complexity of your nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for 
physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 
rehabilitation program. There is not a reasonable expectation that you 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a  crown - porcelain/ceramic (D2740), and core buildup, 
including any pins when required (D2950) both services for tooth #5 provided on December 8, 2022. 
 
You asked the Plan to pay for the dental codes represented by D2740 and D2950. You say that you received a 
2021 Plan dental booklet which has out-of-network allowable amounts listed. You also say that the codes for 
the crown and core build-up are on the list and the services are covered by an out-of-network dentist and should 
be considered for payment. The Plan denied your request.  The Plan says that we have reviewed the documentation the member provided from the 2021 dental benefits 
brochure received, which contains the pages that provides the out-of-network allowances although this claim is 
from date of service December 8, 2022. 
 
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 services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a  crown - 
porcelain/ceramic (D2740), and core buildup, including any pins when required (D2950) both services for 
tooth #5 provided on December 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5254 x 2), the ear impressions  
(V5275 x 2), and the shipping and handling (99999) rendered by the out-of-network (OON) provider on 
September 21, 2022. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says the items 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the items at issue in this appeal. The Plan did not pre-approve the items at issue. We 
found no exception that would require the Plan to pay for these items. Therefore, we decided that the Plan does 
not have to pay for the hearing aids (V5254 x 2), the ear impressions (V5275 x 2), and the shipping and 
handling (99999) rendered by the out-of-network (OON) provider on September 21, 2022.