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

 
We decided that the Plan does not have to pay for magnesium testing provided to the enrollee on March 4, 
2022. 
 
You asked the Plan to pay for the testing. You say that this should be paid for a diagnosis of multiple myeloma, 
remission status unspecified. The Plan denied your request. The Plan says none of the covered signs or 
symptoms were documented in the summitted records. 
 
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 testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this patient with multiple myeloma on oral magnesium underwent laboratory testing for magnesium. 
There is no rationale provided on why patient required a magnesium level. The service is not reasonable or 
medically 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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for magnesium testing provided to the enrollee on March 4, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron 4MG tablet. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the Medicare rules 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 looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the medication have not been met. The enrollee is not receiving chemotherapy. The rules say that 
effective January 1, 1998, Medicare also covers self-administered anti-emetics, which are necessary for the 
administration and absorption of the anti-neoplastic chemotherapeutic agents when a high likelihood of 
vomiting exists. Therefore, we decided that the Plan does not have to pre-approve Ondansetron 4MG tablet.  
 
Benefits for the medication 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cervical, multiple post collar, occipital/mandibular 
supports, adjustable (CPT code L0180) to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that none of the provider in-network 
offer a neck brace. You state you need a neck brace because you have a broken neck. The Plan denied your 
request. The Plan says there are in-network provider(s) within a reasonable distance from your location that can 
provide this service or item. 
 
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 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-approve 
cervical, multiple post collar, occipital/mandibular supports, adjustable (CPT code L0180) to be provided by an 
out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the full upper respiratory infection panel (CPT code(s): 
87502, 87486, 87498, 87496) provided on March 29, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
 
 The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. Your request for the 
codes represent bacterial and viral pathogens tested as part of the single test: (Full Upper Respiratory Infection 
Panel) as confirmed by a review of the methods performed (RT-PCR to detect bacterial and viruses 
simultaneously). Your request does not meet Medicare rules, as the panel performed had more than 6 
pathogens on it. While testing for the bacterial pathogens may have clinical utility in specific patient 
populations, the pathogens are included in the single test (Full Upper Respiratory Infection Panel), which does 
not meet Medicare reasonable and necessary requirements. Therefore, we decided that the Plan does not have 
to pay for the full upper respiratory infection panel (CPT code(s): 87502, 87486, 87498, 87496) provided on 
March 29, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for routine foot care services provided on March 2, 2022. 
 
You asked the Plan to pay for routine foot care services. You say that you have diabetes so foot care should be 
covered. The Plan denied your request. The Plan says that routine foot care is no longer covered. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is 
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or 
feet or have fungal nails.  
 
Records show you may have a condition that results in severe loss of circulation or areas of poor sensation of 
the legs or feet. Specifically, you advised (and the Plan has not disputed) that you have diabetes.  The Plan has 
failed to provide any medical records in this case to disprove your assertion that you meet Medicare criteria for 
coverage of routine foot care.  The Plan says that routine foot care is not covered; however, that is not true.  
Medicare does cover routine foot care for certain indications.  Plans are required to cover at least as much as 
Original Medicare covers. The Plan has failed to show that the foot care you received does not meet Medicare 
criteria for one of these covered indications. The burden is on the Plan to prove that its denial is appropriate. By 
failing to provide any medical records, the Plan has not met this burden. Therefore, we decided that the Plan 
has to pay for routine foot care services provided on March 2, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction (92015) provided on March 25, 2022, and 
the eyeglasses (V2200, V2020) provided on April 5, 2022. 
 
You asked the Plan to pay for the eye refraction and eyeglasses. You say that these services should have been 
covered by your benefits. The Plan denied your request. The Plan says the eye refraction was received though 
an out-of-network provider and was not billed as part of a routine eye exam; therefore, the eye refraction is 
denied. The eyeglasses have been covered up to your allowance amount, and you are responsible for the 
remaining cost. 
 
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 eye refractions when they are performed by a network provider and billed as part of 
a routine eye exam. The Plan will pay up to $100 toward the purchase and fitting of eyeglasses and pair of 
lenses or contact lenses, one per calendar year. You pay any amount over a $100 retail price. 
 
We looked at the file and the Plan's rules. The eye refraction was not billed as part of a routine eye exam and 
was performed by a provider who is not part of the Plans supplemental vision provider network. Based on this 
information, we decided that the Plan's rules for coverage of the eye refraction have not been met. In addition, 
the record shows that the original billed cost of the eyeglasses was $199.99. The Plan paid a portion and 
provided a discount, and you were asked to pay $79.99 for the eyeglasses. This means you have been asked to 
pay the correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not have 
to pay for the eye refraction (92015) provided on March 25, 2022, or any additional amount for the eyeglasses 
(V2200, V2020) provided on April 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a COVID-19 test provided on March 31, 2022. 
 
You asked the Plan to pay for a COVID-19 test. You say that the test was required during a national emergency 
for you to re-enter the US. The Plan denied your request. The Plan says if you receive emergency or urgently 
needed services outside of the United States or its territories, you generally will be required to pay the bill at 
the time you receive the services. 
 
The Plan must follow Medicare rules. Medicare rules say that the routine physical checkup exclusion applies to 
examinations required by third parties such as insurance companies, business establishments, or Government 
agencies. 
 
We looked at the file and Medicare rules. Medicare says that the routine physical checkup exclusion applies to 
examinations required by third parties such as insurance companies, business establishments, or Government 
agencies. Therefore, we decided that the Plan does not have to pay for a COVID-19 test provided on 
March 31, 2022.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for physical therapy for the treatment of temporomandibular joint disorder 
(TMJ) you received from January 20, 2022, to January 31, 2022. 
 
You asked the Plan to pay for physical therapy for the treatment of TMJ. You say that you were provided with 
a list of physical therapists by the Plan.  You said that the Plan never told you that these services would not be 
covered and you would have never gotten these services had you known that. The Plan denied your request. 
The Plan says that these services are not covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were provided physical therapy for the treatment of TMJ by a contract provider. The file does not show 
that the Plan provided notice that these services would not be covered prior to you receiving them. Under 
Medicare rules, this means physical therapy for the treatment of TMJ is considered approved by the Plan. 
Therefore, we decided that the Plan has to pay for physical therapy for the treatment of temporomandibular 
joint disorder (TMJ) you received from January 20, 2022, to January 31, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (88305) provided on March 31, 2021. 
 
You asked the Plan to pay for the lab services. You say that this was not a duplicate procedure and was billed 
appropriately. 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 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 (88305) provided on March 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve total knee arthroplasty for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that this request is not medically necessary because records do not 
show that the enrollee has had 3 months or more of conservative therapy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Detailed 
documentation is not evident regarding a history of unsuccessful appropriate/reasonable conservative therapy 
that is clearly documented in the pre-procedure medical record. Non-surgical medical management is usually 
implemented for 3 months or more to address effectiveness. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Our physician 
reviewer found that the enrollee's condition does not meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve total knee arthroplasty for the enrollee.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
You asked the Plan to pre-approve Injectafer. You say that the clinical documentation provided supports the 
need for the requested drug. The Plan denied your request. The Plan says they did not receive records from the 
prescriber showing that the enrollee has tried one of the preferred drugs and it hasn't worked, or that the 
enrollee has medical records that prevent her from using one of them. 
 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 Injectafer. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the Plan requires a trial of drugs 
Ferrlecit, Infed or Venofer before they will approve the requested drug. In this case, the enrollee has not tried 
and failed the required drugs. There is no documentation provided indicating that the Plans required drugs 
would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that you are afraid that you 
will relapse if you leave the facility now. The Plan denied your request. The Plan says that you do not have 
documentation from your physician substantiating the need for ongoing inpatient treatment. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric hospital services. Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary. It is 
not expected you will improve in a reasonable period of time as you are not showing any dangerousness to self 
or others, auditory or visual hallucinations and without aggressive behaviors while not showing any acute 
threats of safety. It does not appear medically necessary and reasonable to have psychiatric care provided at the 
acute inpatient level of care rather than a lower level of care as you doe not have any suicidal or homicidal 
thoughts, auditory or visual hallucinations or abnormal behaviors. Our physician reviewer found that your 
condition does not meet criteria for coverage of inpatient psychiatric hospital services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric hospital services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient psychiatric hospital services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the physical therapy services (CPT code 97162) to be 
provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the enrollee is currently unable to 
drive or ride as extended car rides cause severe pain. You state the enrollee must rely on someone else to drive 
them to appointment and this clinic is the only physical therapy clinic in this enrollees hometown. The nearest 
in network facility is more than 40 miles. The Plan denied your request. The Plan says this provider is not a 
network provider for this service and there are other in-network providers available within a reasonable 
geographic distance. 
 
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 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-approve the physical therapy services (CPT code 
97162) to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical and imaging services rendered on March 17, 
2022. 
 
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 billed correctly. 
 
The Plan must follow Medicare rules. The rules say that services rendered to a patient who is a registered 
inpatient shall report the inpatient hospital POS code 21. 
 
We looked at the file and Medicare rules. The file shows that the enrollee was under inpatient status for the 
date of service at issue and the claim was not billed with the POS code 21. Therefore, we decided that the Plan 
does not have to pay for the surgical and imaging services rendered on March 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0453 billed for date of service January 19, 
2022. 
 
You asked the Plan to pay for procedure code G0453. You say that the services were medically necessary. The 
Plan denied your request. The Plan says payment for code G0453 is bundled into payment for code 95955.  
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 code G0453 
is a column II code to column I code 95955. 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 code G0453 billed for date of service January 19, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses (V2020, V2781) provided on April 9, 2022. 
 You asked the Plan to pay for eyeglasses. You say that these eyeglasses should be covered by your Plan. The 
Plan denied your request. The Plan says out-of-network services are only covered when they are pre-approved 
by the Plan. These eyeglasses were not pre-approved to be received from an out-of-network provider, and 
could have been received from a network provider. 
 
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 out-of-network services only when they are urgent/emergent or pre-approved. 
 
We looked at the file and the Plan's rules. The provider in this case is out-of-network, and the eyeglasses were 
not pre-approved. Based on this information, we decided that the Plan's rules for coverage of eyeglasses have 
not been met. Therefore, we decided that the Plan does not have to pay for the eyeglasses (V2020, V2781) 
provided on April 9, 2022.