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

 
We decided that the Plan does not have to waive the cost share for an office visit provided on February 23, 
2022. 
 
You asked the Plan to waive the cost share for an office visit. You say that you shouldn't have to pay for this 
service. The Plan denied your request. The Plan says the cost share applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $300 deductible and 20% coinsurance which applies to office visits.  
 
The item or service you asked the Plan to waive the cost share for falls within the benefit category 
Physician/Practitioner Services, Including Doctors Office Visits. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is $300 deductible which applies to Physician/Practitioner Services, 
Including Doctors Office Visits. This cost sharing is a contractual obligation that had not been met at the time 
an office visit was received on February 23, 2022. Therefore, $26.81 has been applied to meet the deductible. 
 
 You have also been asked to pay $34.23 which is 20% coinsurance for the office visit. 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 the Plan does 
not have to waive the cost for office visit provided on February 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a water flosser. 
 
You asked the Plan to pre-approve a water flosser. You say that the member had a stroke four years ago and 
has periodontal disease so a water flosser is part of the treatment for periodontal disease. The Plan denied your 
request. The Plan says per Medicare guidelines, items that do not meaningfully contribute to the treatment of an 
illness or injury or the functioning of a malformed body member are not covered. A water flosser is a personal 
hygiene accessory that can help remove food particles from your teeth and might help reduce bleeding and gum 
disease but is not generally considered as a substitute for brushing and flossing. 
 
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 a water flosser.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on February 22, 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 procedure code 81232 is 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 81232 is DPYD (dihydropyrimidine dehydrogenase) (eg, 
5-fluorouracil/5-FU and capecitabine drug metabolism), gene analysis, common variant(s) (eg, *2A, *4, *5, 
*6). 
 
We find that CPT code 81232 is not supported in the medical record. Specifically, the records show that the 
specimen was not collected on the billed date of service. 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 laboratory services rendered on February 22, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from December 5, 2021, 
through December 11, 2021. 
 
You asked the Plan to pay for the home health services as billed. You say that this claim should be paid like the 
others. You have a contract with the Plan to pay a flat rate per visit for these services. This claim is billed 
correctly. The Plan denied your request. The Plan says this was not submitted on a valid TOB for home health 
services. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a limited set of valid TOBs for home 
health claims.  
 
We looked at the file and Medicare rules. TOB 0323 is not a valid home health TOB for Medicare payment. Based on this information, we decided that Medicare rules for coverage of the home health services as billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the home health services 
provided from December 5, 2021, through December 11, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dulera. 
 
You asked the Plan to pre-approve Dulera. You say that the medication is necessary. The Plan denied your 
request. The Plan says your plan does not have a Medicare Part D benefit, or a separate pharmacy benefit 
managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 Dulera.  
 
Benefits for Dulera 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 Freestyle Lite Test strips (A4253). 
 
You asked the Plan to pre-approve the diabetic testing supplies. You say that you need renewal of your test 
strips, and it was denied. You are a type 2 diabetic, and you need these test strips as soon as possible. The Plan 
denied your request. The Plan says there is no documented medical reason why you cannot use Lifescan testing 
supplies. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.   
We looked at this the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the diabetic testing supplies have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Freestyle Lite Test strips (A4253).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital visit services provided on December 29, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for outpatient hospital visit services. You say that the services provided were 
medically necessary. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 outpatient hospital visit services provided on 
December 29, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the requested out-
of-network provider. 
 
You asked the Plan to pre-approve physician's services to be provided by the requested out-of-network 
provider. The Plan denied your request. The Plan says that the Plan does not cover out-of-network services 
rendered with the exceptions of emergency care or urgently needed services that you get from an out-of-
network provider. This includes worldwide coverage if covered by your Plan. If you need medical care that 
Medicare requires our plan to cover and providers in our network cannot provide this care, you can get this care 
from an out-of-network provider. If you do not have a prior authorization before you receive 
services from an out-of-network provider, you may have to pay for these services yourself and renal dialysis 
services when you are temporarily outside the service area, or when prior authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by the requested out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93308, 03321, and 93325 billed for date of 
service August 10, 2021. 
 You asked the Plan to pay for procedure codes 93308, 03321, and 93325. You say that you disagree with the 
denial. The Plan denied your request. The Plan says payment for codes 93308, 03321, and 93325 is bundled 
into payment for code 33361. 
 
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 codes 
93308, 03321, and 93325 are column II codes to column I code 33361. 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 codes 93308, 03321, and 93325 
billed for date of service August 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telephone evaluation (99441) provided on December 7, 
2021. 
 
You asked the Plan to pay for a telephone evaluation. You say that this should be covered. The Plan denied 
your request. The Plan says this cannot be paid as 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 99441 is telephone evaluation and management service 
by a physician or other qualified health care professional who may report evaluation and management services 
provided to an established patient, parent, or guardian not originating from a related E/M service provided 
within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest 
available appointment; 5-10 minutes of medical discussion . 
 
We find that CPT code 99441 is not supported in the medical record. Specifically, the record shows that the 
enrollee received an evaluation and management service with the same provider in the previous 7 days on 
November 30, 2021. Based on this information, we decided that Medicare rules for coverage of a telephone evaluation have not been met. Therefore, we decided that the Plan does not have to pay for a telephone 
evaluation (99441) provided on December 7, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the 27 immunohistochemical (IHC) antibody stains performed on 
August 13, 2021, billed with one unit of 88342 and 26 units of 88341. 
 
You asked the Plan to pay for the billed number of IHC stains. You say that this is clearly supported by the 
medical records and was necessary to diagnose the enrollee's cancer. The Plan denied your request. The Plan 
says that there was no pathology report submitted for review, so the units in excess of the MUE cannot be 
validated. 
 
Please note: Though the Plan indicated there was no pathology report, we reviewed the file and found the 
report on pages 427 and 428 of the case file submitted by the Plan.  
 
The Plan follows Medicare rules. Medicare rules say that MUEs with an MAI of 3 may be overridden if there is 
evidence that they correctly describe the services rendered and that the services were 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 billed number of IHC stains. Our 
reviewer says that the documentation supports that the reported units of service are correct, and that the testing 
provided was reasonable and necessary. Our physician reviewer found the pathology report included with the 
hospital records clearly lists the different stains performed on the liver biopsy sample. Because this testing was 
done on an occult malignancy, the use of this number of stains is considered 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 billed number of IHC stains have been met. Therefore, we decided that the 
Plan has to pay for the 27 immunohistochemical (IHC) antibody stains performed on August 13, 2021, billed 
with one unit of 88342 and 26 units of 88341.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nyvepria (Q5122). 
 
You asked the Plan to pre-approve Nyvepria. You say that this is medically necessary. The Plan denied your 
request. The Plan says step therapy requirements 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 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 Nyvepria. Our reviewer says that the 
requirements for coverage of Nyvepria have not been met. Our physician reviewer found the Plan requires a 
trial of two of the drugs Neulasta (pegfilgrastim), Fulphila (pegfilgrastim-jmdb), and Udenyca (pegfilgrastim-
cbqv) before they will approve the requested drug. he provided records do not indicate that the enrollee has 
tried and failed two of these drugs. The records also do not indicate that these drugs would likely be less 
effective or 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 Nyvepria have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Nyvepria (Q5122).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the requested out-
of-network provider. 
 
You asked the Plan to pre-approve physician's services to be provided by the requested out-of-network 
provider. The Plan denied your request. The Plan says the Plan does not cover out-of-network services 
rendered with the exceptions of emergency care or urgently needed services that you get from an out-of-
network provider. This includes worldwide coverage if covered by your Plan. If you need medical care that 
Medicare requires our plan to cover and providers in our network cannot provide this care, you can get this care 
from an out-of-network provider. If you do not have a prior authorization before you receive 
services from an out-of-network provider, you may have to pay for these services yourself and renal dialysis 
services when you are temporarily outside the service area, or when prior authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by the requested out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for a fitness membership. 
 
You asked the Plan to pay an additional amount for a fitness membership. You say that you want the Plan to 
pay an additional amount. The Plan denied your request. The Plan says the reimbursement benefit was applied 
correctly. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
 
The Plans rules for coverage of gym benefits have not been met because the Plan did not receive proof of 
payment for the remaining amount. Therefore, we decided that the Plan does not have to pay an additional 
amount for a fitness membership.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the replacement sacral nerve neurostimulator, including 
replacement wire and a longer lasting generator (CPT code 64561). 
 
You asked the Plan to pre-approve the services. You say that the enrollee needs replacement per X-ray, the 
implant has little as two (2) years of charge left. You state the new replacement will have lifetime charge of 10-15 years to avoid future surgery and anesthesia on this geriatric enrollee. You state the procedure is scheduled 
for August 30, 2022. The Plan denied your request. The Plan says given that the current device is fully 
functional, and the battery has sufficient battery life, it does not agree that a full explant and replacement with 
another unit is medically necessary; however, the Plan states they would agree that lead revision may be 
medically necessary. The Plan states they would deny the full explant and replacement of the unit; however, the 
Plan would endorse coverage of lead revision if a separate request for this specific procedure is requested. 
 
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 services. Our physician reviewer 
found the medical records provided do not meet the requirements listed in the NCD for Medicare coverage. 
The records show that reprogramming has improved symptoms with battery life remaining is 29-50 months, 
and do not show lead fracture or displacement. 
 
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 pre-approve the replacement sacral nerve neurostimulator, including replacement wire and a longer 
lasting generator (CPT code 64561).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Myrbetriq. 
 
You asked the Plan to pre-approve Myrbetriq. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 Myrbetriq.  
 
Benefits for Myrbetriq 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 90686 and G0008 billed for date of service 
November 3, 2021. 
 
You asked the Plan to pay for procedure codes 90686 and G0008. You say that you disagree with the denial. 
The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure codes 90686 and G0008 have a Status Indicator of X on the Physician Fee Schedule. 
This means that procedure codes 90686 and G0008 are not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure codes 90686 and G0008 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 90686 and G0008 billed for 
date of service November 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the extraction, of an erupted tooth or 
exposed root (D7140) provided on March 3, 2022. 
 
You asked the Plan to issue reimbursement 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 payable as you 
have exhausted the allowable dental benefit for this calendar year. 
 
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.   
 
We looked at the case file and the Plan's rules. Based on this information, we decided that you have exhausted 
the allowable dental benefit for this calendar year. Specifically, the Plan contract states that the Plan reimburses 
up to $1,000 every year for non-Medicare covered preventive dental services and non-Medicare-covered 
comprehensive dental services combined.  The Plan issued reimbursement to you previously on June 1, 2022 in the amount of $1,000. Therefore, you have exhausted the allowable dental benefit for coverage of this service. You are responsible for any amount above the dental coverage limit. Therefore, we decided that the Plan does not have to issue reimbursement for the extraction, of an erupted tooth or exposed root (D7140) provided on March 3, 2022.