Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Darzalex Faspro. 
 
You asked the Plan to pre-approve Darzalex Faspro. 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. 
 
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 Darzalex Faspro. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the enrollee has not tried and failed 
the required drug. 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 Darzalex Faspro have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Darzalex Faspro.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on July 26, 
2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that this should be covered. The 
Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $410 
copayment for Outpatient surgery. 
 
You have been asked to pay a $410 copayment for outpatient surgery. This item/service falls within the 
Outpatient surgery 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. You have been asked to pay $234.47 which is less than the standard $410 copayment for outpatient 
surgery. Therefore, we decided that the Plan does not have to waive the copayment for outpatient surgery 
provided on July 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing to resin-based composite - four or more 
surfaces or involving incisal angle (anterior) (D2335) provided on July 14, 2022. 

You asked the Plan to waive the cost-sharing applies to code D2355. You say that originally you were told you 
were seeing an in-network provider, but later found out the provider was actually out-of-network. The Plan 
denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 50% 
coinsurance for basic restorative services when provided by an in- or out-of-network provider. 
 
You have been asked to pay $73, which is 50% of the allowed amount for resin-based composite - four or more 
surfaces or involving incisal angle (anterior) (D2335). The allowed amount is $146 (50% x $146 = $73). Resin-
based composite - four or more surfaces or involving incisal angle (anterior) (D2335) falls within the Basic 
Restorative Services 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 cost-sharing applies to resin-based 
composite - four or more surfaces or involving incisal angle (anterior) (D2335) provided on July 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88360, 88381, and 88342 billed for 
date of service January 28, 2022. 
 
You asked the Plan to pay for procedure code(s) 88341, 88360, 88381, and 88342. You say that you would like 
the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says these codes are 
included in the facility payment and are 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 facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88360, 88381, 
and 88342. This means there is both a professional and technical component for the CPT code(s). In this case, 
an appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88341, 
88360, 88381, and 88342. Based on this information, we decided that Medicare rules for coverage of procedure 
codes 88341, 88360, 88381, and 88342 have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure code(s) 88341, 88360, 88381, and 88342 billed for date of service January 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Limited oral evaluation - problem focused, removal of 
impacted tooth - completely bony, deep sedation/general anesthesia, each subsequent 15-minute increment and 
inhalation of nitrous oxide/analgesia, anxiolysis provided on September 15, 2022, to September 20, 2022. 
 
You asked the Plan to pay for dental services. You say that these services should be covered by insurance 
because your PCP referred you to the oral surgeon. The Plan denied your request. The Plan says these services 
are not covered under your Plan.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Limited oral evaluation - 
problem focused, removal of impacted tooth - completely bony, deep sedation/general anesthesia, each 
subsequent 15-minute increment and inhalation of nitrous oxide/analgesia, anxiolysis are not covered under the 
Plan's dental benefits. 
 
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 Limited 
oral evaluation - problem focused, removal of impacted tooth - completely bony, deep sedation/general 
anesthesia, each subsequent 15-minute increment and inhalation of nitrous oxide/analgesia, anxiolysis provided 
on September 15, 2022, to September 20, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 12, 2022, to 
January 20, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.   
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 12, 2022, to 
January 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the revision of total knee arthroplasty services coded 27486 
provided on July 23, 2022. 
 
You asked the Plan to pay for the revision of total knee arthroplasty services. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the services billed are not supported. 
 
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, the CPT Code Manual definition of code 27486 is revision of total knee arthroplasty, with or 
without allograft; 1 component. 
 
We find that CPT code 27486 is not supported in the medical record. Specifically, the operative report did not 
include documentation of a revision of a total knee arthroplasty for 1 component, with or without allograft; 
therefore, this code cannot be verified. Based on this information, we decided that Medicare rules for coverage 
of the revision of total knee arthroplasty services have not been met. Therefore, we decided that the Plan does 
not have to pay for the revision of total knee arthroplasty services coded 27486 provided on July 23, 2022.
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 76942. We decided that the Plan does not have to pay 
for procedure code 64421. 
 
You asked the Plan to pay for procedure codes 64421 and 76942 billed for date of service July 8, 2022. You 
say that you disagree with the denial. The Plan says that procedure code 64421 exceeds the MUE value and 
code 76942 is inclusive to 20553. 
 
We decided that the Plan has to pay for procedure code 76942. 
 
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. The Plan states that code 76942 is not separately payable because it is inclusive 
to code 20553; however, there are no active edits for this code stating that it is inclusive to 20553. The Plan has 
not provided any documentation to support that code 76942 is not payable as billed. Therefore, we decided that 
the Plan has to pay for procedure code 76942 billed for July 8, 2022. 
 
We also decided that the Plan does not have to pay for procedure code 64421. 
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 64421 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 64421 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 64421 billed for date of service July 8, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for injection provided on September 20, 2022. 
 
You asked the Plan to waive the copayment for injection. You say that this should be covered. The Plan denied 
your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $75 
copayment for Outpatient procedures and services. 
 
You have been asked to pay a $75 copayment for injection. This item/service falls within the Outpatient 
procedures and services 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 injection 
provided on September 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20660-AS provided on June 24, 2022. 
 
You asked the Plan to pay for procedure code 20660-AS. You say that this service should be paid. The Plan 
denied your request. The Plan says the claim processed correctly. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 20660-AS. The Medicare Fee Schedule Database contains a surgical 
indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not 
medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria 
for procedure code 20660-AS have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 20660-AS provided on June 24, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on July 31, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says services provided out-of-network require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan 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 physician services provided on July 31, 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 the home health services provided from May 8, 2022, to June 
6, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.   
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from May 8, 2022, to June 6, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) provided on August 31, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99202) provided on August 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiovascular risk assessment with a PULS (Protein 
Unstable Lesion Signature) test provided on April 28, 2022. 
 
You asked the Plan to pay for cardiovascular risk assessment with a PULS test. You say that this claim should 
be covered. The Plan denied your request. The Plan says this service was performed for screening purposes and 
is therefore 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, cardiovascular risk assessment with a PULS test, 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 cardiovascular risk assessment with a PULS (Protein Unstable Lesion 
Signature) test provided on April 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical nerve stimulation supplies billed with code 
E0730 for September 2, 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 there is no valid proof of delivery. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS 
suppliers are required to maintain proof of delivery. 
 
We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 electrical nerve stimulation supplies billed with code 
E0730 for September 2, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the dental services provided on March 3, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that they were unable to make a determination 
within the allotted time frame. 
 
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. In this case, the Plan did not provide enough evidence to support the denial of 
payment for the services provided on March 3, 2022. Therefore, we decided that the Plan has to pay for the 
dental services provided on March 3, 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy visits provided on July 26, 
2022. 
 
You asked the Plan to waive the copayment for physical therapy visits. You say that you were told there would 
be no charge for this. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for outpatient rehabilitation services. 
 
You have been asked to pay a $20 copayment for physical therapy visits. This item/service falls within the 
outpatient rehabilitation services 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. You have been asked to pay $240 ($20 x 12 visits) copayment for the physical 
therapy visits. Therefore, we decided that the Plan does not have to waive the copayment for physical therapy 
visits provided on July 26, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for an ultrasound and injection provided on July 
20, 2022. 
 
You asked the Plan to waive the cost share for an ultrasound and injection. You say that this should be covered. 
The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for injections and a $100 copayment for an ultrasound.  
 
 
 
 
 You have been asked to pay $66.42 which is less than the standard amount for an ultrasound and injection. 
These items/services fall within the Medicare Part B prescription drugs benefit category and 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 
cost share for an ultrasound and injection provided on July 20, 2022.