Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiation treatment provided on March 29, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for radiation treatment. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says this provider is not a contracted provider. The Plan also says that there 
are many contracted providers in the area for radiation oncology that are familiar with plan benefits, including 
the prior authorization requirements for radiation oncology. 
 
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 radiation treatment provided on March 29, 2022, 
by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-rays (73130 & 73090) provided on March 31, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the x-rays. You say that the services were medically necessary. The Plan denied 
your request. The Plan says the services were provided out-of-network and were not 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 the x-rays (73130 & 73090) provided on March 
31, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve reverse total shoulder replacement (23472) 
 
You asked the Plan to pre-approve the surgical procedure. You say that you are requesting an appeal for denial 
of right shoulder surgery. The Plan denied your request. The Plan says reverse total surgery is considered not 
medically necessary in the treatment of shoulder dysfunction. 
 
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 the surgical procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was being treated for primary osteoarthritis of the right shoulder. She 
presented with right shoulder symptoms after sustaining a dislocation anteriorly to her right shoulder. She 
underwent a closed reduction successfully. She has been in a sling for 1 week. The pain seems to be improving, 
but she is unable to lift up her arm. She has significant weakness in her arm. There is noted numbness, tingling 
and popping of the right shoulder.  However, detailed documentation is not evident regarding the necessity of a 
reverse total shoulder arthroplasty (including but not limited to the possibility of a rotator cuff repair.) She has 
significant weakness in her arm. The range of motion forward flexion 60, abduction 60, external rotation 30, 
and internal rotation to the lumbar spine. Such motion and strength deficits are relative contraindications to the request. There are limited large-scale, long-term references showing the safety and efficacy of the requested 
surgery in this clinical setting. There is no compelling rationale presented or extenuating circumstances noted 
to support the medical necessity of this request as an exception to guidelines. Therefore, the requested reverse 
total right shoulder replacement (23472), in this case, 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 surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve reverse total shoulder replacement (23472)
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on January 4, 2022. 
 
You asked the Plan to pay for the physician's services. You say that your husband went to a dermatologist who 
is a MOHLS specialist to remove a cancerous tissue on his neck and you did not ask about authorizations or 
in-network providers because the cancer just needed to be removed and tested right away. You say this service 
was absolutely necessary and needed to be done immediately. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers 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 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 physician's services provided on January 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99140 billed on November 19, 2021. 
 
You asked the Plan to pay for procedure code 99140. You say that the attached medical records should be 
reviewed. The Plan denied your request. The Plan says procedure codes 01961 has been overturned and 
procedure code 99140 remains denied as bundled services are not eligible for separate payment. 
 
  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99140 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99140 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of procedure code 99140 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99140 billed on November 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve topical Opzelura cream. 
 
You asked the Plan to pre-approve Opzelura cream. You say that the requested drug was recently approved by 
the Food and Drug Administration (FDA) for the treatment of the enrollee's condition. You also say that you 
feel you the enrollee needs access to this drug. The Plan denied your request. The Plan says the topical 
Opzelura cream was denied correctly. 
 
 
 
 
 
 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 topical Opzelura cream.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health services provided from September 28, 2021, through 
October 26, 2021. 
 
You asked the Plan to pay for the home health services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says that payment is not allowed for this service 
because it is not appropriate for the codes billed. 
 
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 has denied coverage by stating that payment is not allowed 
for this service because it is not appropriate for the codes billed. There is no indication presented by the Plan 
why these codes are not supported for payment. The Plan has failed to present a valid denial reason for why 
these codes are not paying.  Therefore, we decided that the Plan has to pay for the home health services 
provided from September 28, 2021, through October 26, 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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mobile cardiac outpatient telemetry (MCOT) monitor 
 
You asked the Plan to pre-approve a MCOT monitor. You say that you have palpitations, and the requested 
service is medically necessary. The Plan denied your request. The Plan says the request is not medically 
necessary. 
 
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 a MCOT monitor. Our reviewer says 
that an MCOT monitor not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is no documentation provided to support that the diagnosis of a significant cardiac arrhythmia as 
the cause of the enrollee's symptoms could only be established with an MCOT monitor with real-time 
telemetry. There is no supportive evidence that the ordering practitioner documented that other testing and 
electrocardiogram (ECG) monitoring had been negative. A 30-day ambulatory ECG monitor has not been 
performed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a MCOT monitor have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a mobile cardiac outpatient telemetry (MCOT) monitor
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 23, 2021, billed with 
codes 81206 and 81292. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says the testing 
was billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
August 23, 2021, billed with codes 81206 and 81292.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120), 
intraoral - periapical first radiographic image (D0220), and intraoral - periapical each additional radiographic 
image (D0230) provided January 26, 2022. 
 
You asked the Plan to pay for the periodic oral exam and periapical x-rays. You say that you cannot afford the 
cost of these services. The Plan denied your request. The Plan says you have exhausted your dental benefit. 
 
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 periodic 
oral exam and periapical x-rays when the services are medically necessary and reasonable.  
 
 
 We looked at the file and Medicare rules. The Plan provided documentation showing that your full $1,000 
annual maximum was applied to dental service received February 16, 2022.  Therefore, we decided that the 
Plan does not have to pay for the periodic oral evaluation - established patient (D0120), intraoral - periapical 
first radiographic image (D0220), and intraoral - periapical each additional radiographic image (D0230) 
provided January 26, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya (J3245). 
 
You asked the Plan to pre-approve Ilumya. You say that the requested drug is the best treatment option for the 
enrollee at this time. You also say that the preferred drugs are older and would prefer to avoid them. The Plan 
denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, Remicade or 
Avsola. 
 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 Ilumya. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided records do not indicate that the 
enrollee has tried and failed one of the plan's preferred step one alternative, Remicade or Avsola. The record 
does not indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's 
preferred step one alternative. Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ilumya have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Ilumya (J3245).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on April 12, 2021. 
 
You asked the Plan to pay for the lab services. 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 the lab services provided on April 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for hospital observation provided on January 
12, 2022, to January 13, 2022. 
 
You asked the Plan to waive the copayment for hospital observation. You say that you are requesting a 
reconsideration of the copayment. The Plan denied your request. The Plan says the coinsurance is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $295 
copayment for Medicare-covered outpatient hospital observation.  
 
You have been asked to pay $295 copayment for hospital observation. Hospital observation falls within the 
Outpatient Hospital Observation 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 
hospital observation provided on January 12, 2022, to January 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 6, 2021, billed with 
codes 81318, 81309, 81299, 81404, 81404, 81403, 81403, 81402, 81401, 81401, 81400, 81270, 81321, 81314, 
81311, 81310, 81276, 81275, 81235, 81210, 81121 and 81120. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like this claim reprocessed 
based on the medical The Plan denied your request. The Plan says the claim has not been billed as required by 
Medicare billing regulations. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
July 6, 2021, billed with codes 81318, 81309, 81299, 81404, 81404, 81403, 81403, 81402, 81401, 81401, 
81400, 81270, 81321, 81314, 81311, 81310, 81276, 81275, 81235, 81210, 81121 and 81120.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an over-bed table. 
 
You asked the Plan to pre-approve an over-bed table. You say that you are bedridden and need to eat in the 
bed. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an over-bed table.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuous glucose monitor supplies (K0554, K0553). 
 
You asked the Plan to pre-approve the continuous glucose monitor supplies. You say that these items are 
medically necessary. The Plan denied your request. The Plan says rules for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the continuous glucose monitor supplies have not been met. Therefore, we decided that the Plan does not have 
to pre-approve continuous glucose monitor supplies (K0554, K0553).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft (D7953) provided by a participating 
provider on January 5, 2022. 
 
You asked the Plan to pay for a bone replacement graft. You say that you do not agree with this denial. The 
Plan denied your request. The Plan says the dental work provided is not a covered benefit. 
 
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 bone 
replacement graft (D7953) provided by a participating provider on January 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lightweight wheelchair (K0003). 
 
You asked the Plan to pre-approve a lightweight wheelchair. You say that you are unable to leave your house 
and had to cancel several medical and dental appointments as you do not have the proper equipment for 
transportation. The Plan denied your request. The Plan says you already have a manual wheelchair to be used at 
home. The requested DME is a duplicate of what you already have. Furthermore, the Plan also says you can 
avail your transportation benefits which can help with transportation to your appointments. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home. The rules also say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. The records also show that you currently 
have a manual wheelchair for use in the home. Therefore, we decided that the Plan does not have to pre-
approve a lightweight wheelchair (K0003).