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

 
We decided that the Plan does not have to pay for the services provided on September 18, 2022. 
 
You asked the Plan to pay for the services. 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 services at issue were reimbursed 
by the Plan on October 19, 2022. Comparison of the two claims shows these are exact duplicates. There is no 
evidence presented to support that the billed services were provided twice on the same date. Based on this 
information, we decided that the Medicare rules for the services have not been met. Therefore, we decided that 
the Plan does not have to pay for the services provided on September 18, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Keytruda (J9271). 
 You asked the Plan to pre-approve Keytruda. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage have not been met. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve Keytruda as part of a clinical trial. The Plan does not cover 
routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-
approve treatment with Keytruda (J9271).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wrist hand orthosis, includes one or more nontorsion 
joint(s), elastic bands, turnbuckles, may include soft interface, straps, prefabricated, off-the-shelf provided to 
the enrollee on August 8, 2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the documentation did not sufficiently support the billed supply code. 
 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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the provided medical records do not document any detail with regard to an upper extremity problem 
for which the hand/wrist orthosis was ordered. Provided medical records do not document the orthosis as part 
of the treating practitioner's plan of care for the patient. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for a wrist hand orthosis, includes one or more nontorsion joint(s), elastic bands, turnbuckles, may 
include soft interface, straps, prefabricated, off-the-shelf provided to the enrollee on August 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro Motion G orthotic. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the MyoPro is not the standard of care 
for the enrollee's condition or in widespread use for her condition based on scientific evidence. There is 
insufficient evidence in the literature that the MyoPro Orthosis will improve the long term outcomes for the 
enrollee. There is insufficient evidence in the literature that this device will increase  participation in bimanual 
activities. The services are therefore 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a MyoPro Motion G orthotic.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (76376) provided on May 13, 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 this service is not covered when provided OON. 
 
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 lab services (76376) provided on May 13, 
2022, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee would strongly benefit from a skilled 
nursing facility. The Plan denied your request. The Plan says the enrollee has not had a change in function that 
warrants daily skilled therapy services and has no daily skilled nursing needs. Based on the current needs, we 
are denying coverage for this admission or transfer to a SNF. The enrollee's needs can be met safely at an 
alternate level of care. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's medical history, commodities, current 
medical needs, the severity of presenting signs and symptoms, the medical predictability of adverse events, the 
types and appropriateness of care that is available in an inpatient rehabilitation facility is medically necessary, 
reasonable, and appropriate. The Plan denied your request. The Plan says the records show that it is not 
reasonable to expect that the enrollee will be able to fully benefit from the intensity of services of an IRF. The 
enrollee can safely receive the more extended services needed safely in other settings, for example, a skilled 
nursing facility or possibly home with home health services. 
 
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 there are no active medical issues are noted thus the complexity of the patient's 
documented nursing, medical and rehabilitation needs would not be expected to require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit, psychotherapy, and group psychotherapy 
services provided from May 19, 2022, to May 24, 2022. 
 
You asked the Plan to pay for the office visit, psychotherapy, and group psychotherapy services. You say that 
you disagree with the Plan's denial. The Plan denied your request. The Plan says the services rendered are not a 
covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the office visit, psychotherapy, and 
group psychotherapy services provided from May 19, 2022, to May 24, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat transthoracic echocardiography (TTE). 
 
You asked the Plan to pre-approve a repeat TTE. The Plan denied your request. The Plan says medical 
necessity is not met based on the provided information. 
 
The Plan follows Medicare rules. Medicare rules say that absent acute intervention, or a discrete change in 
otherwise stable clinical signs and symptoms, it is not medically necessary to repeat these examinations more 
frequently than annually. 
 
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 repeat TTE. Our physician reviewer 
found that at issue is the medical necessity of a repeat TTE, in the absence of any apparent significant change 
in the enrollees clinical condition. Our reviewer found the clinical guidelines do not support repeating a TTE 
with no intervening change in clinical status or physical findings. Our reviewer also found that there is no 
supportive evidence for the medical necessity of a repeat TTE in this this enrollees clinical management. 
 
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 repeat TTE have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat transthoracic echocardiography (TTE).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided from February 10, 2021, to  
July 22, 2021. 
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says the dates of services 
from February 10, 2021 through February 25, 2021 denied because coverage with the Plan became effective on 
March 1, 2021. Additionally, dates of service from March 4, 2021 through July 22, 2021 denied for timely 
filing limitations. The claim was not received until July 27, 2022. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for psychotherapy was not filed until July 27, 2022. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Additionally, your complaint is 
not a valid appeal for medical coverage for the dates of service February 10, 2021 through February 25, 2021 
because you were not enrolled in the Plan until March 1, 2021. Therefore, we decided that the Plan does not 
have to pay for psychotherapy provided from February 10, 2021, to July 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71046 billed for date of service August 8, 
2022. 
 You asked the Plan to pay for procedure code 71046. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says payment for code 71046 is bundled into 
payment for code 71111. 
 
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 71046 
is a column II code to column I code 71111. 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 71046 billed for date of service August 8, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are unable to walk and need assistance. The 
Plan denied your request. The Plan says a SNF admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a reopening of recent laparotomy (49002) billed for date of 
service June 14, 2022. 
 
You asked the Plan to pay for a reopening of recent laparotomy. You say that the services at issue have been 
billed correctly. The Plan denied your request. The Plan says the available records do not support the service 
billed. 
 
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 49002 is: Reopening of recent laparotomy. 
 
We asked our coder 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 a reopening of recent laparotomy. Our reviewer says that the 
procedure code at issue does not meet criteria for payment. Our reviewer found that the operative report 
indicates the enrollee returned to operating room for a re-laparotomy; however, a decision was made for an 
open procedure. Therefore, a more comprehensive procedure would be reported in this case, and procedure 
code 49002 would be inappropriate to report.  
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a reopening of recent laparotomy have not been met. Therefore, we decided that 
the Plan does not have to pay for a reopening of recent laparotomy (49002) billed for date of service June 14, 
2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit on July 27, 2022. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that you went to the 
emergency room, but you were not treated. 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 $90 
copayment for each emergency care visit.  
 
You have been asked to pay a $90 copayment for the emergency room visit. This item/service falls within the 
emergency care 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 the emergency room visit 
on July 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for fabricated abutments (D6057), abutment supported retainer 
(D6068), and a pontic (D6245) for tooth #18, #19, and #20. 
 
You asked the Plan to pay for the dental services. You say that you are displeased with the coverage the Plan 
provides. The Plan denied your request. The Plan says the denial of payment for these services is correct, 
because fabricated abutments, abutment supported retainer, and pontics are not covered by the Plan. 
 
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 fabricated 
abutments (D6057), abutment supported retainer (D6068), and a pontic (D6245) for tooth #18, #19, and #20.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the DecisionDx-SCC test provided on August 18, 2022. 
 
You asked the Plan to pay for the DecisionDx-SCC test. You say that the DecisionDx-SCC test is covered by 
Medicare. The Plan denied your request. The Plan says that the DecisionDx-SCC test is 
experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 DecisionDx-SCC test. Our reviewer says 
that the DecisionDx-SCC test is considered medically reasonable and necessary in this case. Our physician 
reviewer found that the DecisionDx-Melanoma test is a 31-gene expression profile (GEP) that determines a 
CM patient's risk for metastatic disease. The test classifies patients as having a tumor with low (Class 1) or 
high (Class 2) risk for developing metastasis within 5 years of diagnosis. Patients with a Class 1 tumor profile 
also have a low likelihood of being sentinel lymph node (SLN) positive. Thus, the individualized risk profile 
result of this test can be used to guide use of sentinel lymph node biopsy in the context of patient-specific 
management plans. The DecisionDx-Melanoma test is covered only for Medicare enrollees. The review has 
determined that the requested DecisionDx-SCC test at issue in this case is medically reasonable and 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 DecisionDx-SCC test have been met. Therefore, we decided that the Plan 
has to pay for the DecisionDx-SCC test provided on August 18, 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 the DecisionDx-SCC test provided to the enrollee on June 9, 
2022. 
 
You asked the Plan to pay for the testing. You say that this was medically necessary. The Plan denied your 
request. The Plan says this test is experimental and investigational. 
 
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 although this test is now commercially available and clinically validated, there are no adjuvant therapies 
approved. There is risk and it will not benefit the patient. 
 
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 the DecisionDx-SCC test provided to the enrollee on June 9, 2022.