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

 
We decided that the Plan does not have to pay for the Tempus gene panel provided on June 7, 2021, billed with 
13 genetic testing codes. 
You asked the Plan to pay for the Tempus gene panel. You say that this is medically necessary testing. The 
Plan denied your request. The Plan says POS 81 is not appropriate to report these services. 
 
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 Tempus gene panel 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 Tempus gene panel provided on June 7, 2021, billed with 13 genetic 
testing codes.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ocrevus (J2350) and the administration (96415 and 
96413). 
 
 
 
 You asked the Plan to pre-approve Ocrevus and the administration. You say that currently, Ocrevus is the only 
disease modifying therapy that is approved by the Food and Drug Administration to treat progressive forms of 
multiple sclerosis. The Plan denied your request. The Plan says the enrollee does not have any stated 
contraindications to the preferred products, and has not tried any of the preferred agents. The Plan also says 
that a rationale is not provided for the use of the non-preferred product for safety or efficacy. 
 
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 Ocrevus and the administration. Our 
reviewer says that Ocrevus is not medically reasonable and necessary for the enrollee. Our physician reviewer 
found the enrollee has not tried and failed the required drug, Kesimpta. Our reviewer also found that there is no 
indication that the Plan's required drug 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 Ocrevus and the administration have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Ocrevus (J2350) and the administration (96415 and 96413).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral exam (D0140) provided on June 30, 2021, 
and the root canal services (D3320, D3331) provided on July 14, 2021. 
 
You asked the Plan to pay for the limited exam and root canal services. You say that you were not told that this 
care would not be covered prior to services. The Plan denied your request. The Plan says these services are not 
covered by 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 Plan's 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 the 
limited oral exam (D0140) provided on June 30, 2021, and the root canal services (D3320, D3331) provided on 
July 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the F2 gene analysis and F5 gene analysis services. 
 
You asked the Plan to pre-approve genetic testing services. You say that these services are medically 
reasonable and necessary for the enrollee. The Plan denied your request. The Plan says this testing service is 
not covered for the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that genetic testing for the F5 and F2 gene for all risk 
factors, signs, symptoms, diseases, or conditions, including cardiovascular risk assessment, are non-covered 
except for pregnant patients.   
 
We looked at the file and Medicare rules. In this case, the enrollee is not pregnant. Based on this information, 
we decided that Medicare rules for coverage of genetic testing services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the F2 gene analysis and F5 gene analysis services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network referral for ultrasound of the head 
and neck. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not an emergency, and there are network providers available. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an out-of-network referral for ultrasound of the head and neck.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided the Plan does not have to reimburse you $39.98 for the items purchased November 3, 2021. 
 
You asked the Plan to reimburse you for these items. Your receipt notes state these were blink eye drops. The 
Plan denied your request. The Plan says the proof of payment does not reflect purchases that are eligible for 
this program.  
 
Medicare does not cover over the counter items. The Plan covers limited over the counter items. Chocolate bars 
do not qualify for reimbursement.  Blink drops and nasal mist do not qualify for this reimbursement without 
proper description on the receipt. There also is not a date on the receipt. Therefore, we decided that the Plan 
does not have to reimburse you $39.98 for over-the-counter items purchased November 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral exam (D0150) and four surgical 
extractions (D7210) to be provided by an oral surgeon. 
 
You asked the Plan to pre-approve services provided by an oral surgeon. You say that you were referred for 
these services, and they are medically necessary. The Plan denied your request. The Plan says services 
provided by an oral surgeon are not covered by 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. Your contract with the Plan 
states that dental care is only covered when it is performed by a participating general dentist. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, items or services rendered by a dental 
specialist such as an oral surgeon are not among those covered under this benefit. Therefore, we decided that 
the Plan does not have to pre-approve a comprehensive oral exam (D0150) and four surgical extractions 
(D7210) to be provided by an oral surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair component or accessory, not otherwise 
specified, cup holder (K0108). 
 
You asked the Plan to pre-approve the cup holder. You say that your current wheelchair has a cup holder. You 
cannot hold anything without dropping it or spilling it. This cup holder is a necessity. The Plan denied your 
request. The Plan says this item is a convenience item and is not covered. 
 
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 wheelchair component or accessory, not otherwise specified, cup holder (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213), and a mandibular 
partial denture (D5214) to be provided by a participating provider. 
 
You asked the Plan to pre-approve a maxillary partial denture and a mandibular partial denture. You say that 
you would like the Plan to approve this. The Plan denied your request. The Plan says the benefit limit for 
D5213 and D5214 has already been exhausted. 
 
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 a maxillary 
partial denture and a mandibular partial denture when the services are medically necessary and reasonable.  
 
We looked at the file and Medicare rules. Evidence was provided to show that D5213 and D5214 was provided 
on June 4, 2018. Based on this information, we decided that the Plan's rules for coverage of a maxillary partial denture and a mandibular partial denture have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a maxillary partial denture (D5213), and a mandibular partial denture (D5214) to be provided by 
a participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a second annual preventive exam received on December 3, 
2021. 
 
You asked the Plan to pay for the exam. You say that you were under the impression that this would be 
covered, as you were unaware that a year had not passed. The Plan denied your request. The Plan says this is 
not a covered benefit. 
 
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 rules also say that annual wellness visits are 
covered once per year. 
 
The file shows that the first physical exam was received on February 8, 2021. This would not be covered again 
until February 8, 2022. The second exam was received before this on December 3, 2021. A second exam would 
be considered screening and not covered. Therefore, we decided that the Plan does not have to pay for a second 
annual preventive exam received on December 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional chiropractic treatment. 
 
You asked the Plan to pre-approve additional chiropractic treatment. You say that additional chiropractic 
treatment is medically necessary. The Plan denied your request. The Plan says the member appears to be 
receiving elective and convenience care. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care. 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 additional chiropractic treatment. Our 
reviewer says that additional chiropractic treatment is not medically necessary. Our physician reviewer found 
that the medical record indicates that you have lumbar subluxation and have been receiving chiropractic care.  
The record indicates that the current chiropractic care is maintenance therapy of a chronic condition.  The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules 
of the requested service. The elements of the coverage criteria are not satisfied.  The requested service is not 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional chiropractic treatment have not been met. Therefore, we decided that 
the Plan does not have to pre-approve additional chiropractic treatment.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the clinical assessment does not support the expectation of a 
stay to be at least 25 days. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. You appear 
to require additional wound care but do not require daily physician visits, many hours of nursing care, and there 
are no other complexities that would expect you to require long-term acute care. You do not require services at 
the LTACH that are not available at a skilled nursing facility or via home services. There are no services at the 
LTACH that you require that are not available and covered at a lower level of care. Our physician reviewer 
found that your condition does not meet Medicare criteria for LTACH services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial upper denture (D5213), partial lower denture 
(D5214), retainer crowns (D6740 x 4), and pontics (D6240 x 2). 
 
You asked the Plan to pre-approve the dental services. You say that you feel you were misled by the sales 
agent. You say that you were advised bridges were covered. You also say that you are unable to eat as your 
gums hurt. The Plan denied your request. The Plan says the requested services are not listed as covered dental 
services. 
 
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 partial denture, retainer 
crowns, and pontics are not among those covered under this benefit. Therefore, we decided that the Plan does 
not have to pre-approve a partial upper denture (D5213), partial lower denture (D5214), retainer crowns 
(D6740 x 4), and pontics (D6240 x 2).   
Your complaint about being misled by a sales representative is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One injections (J7325 and 20610). 
 
You asked the Plan to pre-approve the Gel-One injections. You say that you feel the enrollee is an excellent 
candidate for a Viscosupplement injection to the knee. The Plan denied your request. The Plan says this request 
is not medically necessary because the records do not document prior trial of aspiration with trial of intra-
articular corticosteroids or that corticosteroids are not contraindicated.  
The Plan follows Medicare rules. Medicare rules say that viscosupplementation therapy for the knee via intra-
articular injections of hyaluronic preparations will be considered medically reasonable and necessary when all 
of the conditions are met. 
 
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 Gel-One injections. Our reviewer 
says that there is no documentation that the enrollee meets all 5 indications for coverage of the Gel-One 
injections as detailed in the Local Coverage Determination (LCD) - Hyaluronan Acid Therapies for 
Osteoarthritis of the Knee (L35427). Our physician reviewer found the records do not document the enrollee 
has failed to respond to aspiration of the knee when effusion is present and intra-articular corticosteroid 
injection therapy when inflammation is a significant component of the patients symptoms and intra-articular 
corticosteroids are not contraindicated. 
 
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 Gel-One injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Gel-One injections (J7325 and 20610).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee no longer needs to remain in the 
hospital but has ongoing skilled care needs which need to be provided in an SNF. The Plan denied your 
request. The Plan says the criteria for admission to an SNF are not met. The skilled services the enrollee 
requires can be provided on an intermittent outpatient basis, in a long-term care facility, or at home with home 
health care services. 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 daily 
skilled services are not necessary. Our physician reviewer found that based on the medical records provided, 
there is no documentation that the enrollee requires skilled nursing services that require the specialized skill, 
knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary 
and reasonable treatment. Records do not document the need for intravenous medications, new tube feeding, or 
ostomy care or daily complex wound care. Based on the medical records provided, the enrollee does not require 
skilled therapy services which require the specialized skill, knowledge and judgement of a qualified therapist to 
safely and effectively provide medically necessary and reasonable therapy services. The provided records do 
not document a significant decline in the enrollees functional status compared to her recent baseline to 
necessitate daily inpatient skilled therapy services. There is no documentation that daily skilled services are 
required. As a practical matter, there is no documentation that the enrollee requires services on an inpatient 
setting as provided only in a skilled nursing facility setting. Custodial care in assisted living facility or in a 
long-term care facility appears appropriate in this case. 
 
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) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer crown (D6750). 
 
You asked the Plan to pre-approve a retainer crown. You say that the requested service is necessary. The Plan 
denied your request. The Plan says the service is a covered benefit, but you have exceeded the frequency limit 
of 3 per calendar year. 
 
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.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a retainer crown have not been met. Specifically, the record shows that you have exceeded the 
frequency limit for this service. Therefore, we decided that the Plan does not have to pre-approve a retainer 
crown (D6750).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the rhythm electrocardiogram (EKG) rendered on August 12, 2021. 
 
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 that procedure code 93042 is not separately payable. 
 
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 procedure code 93042 (rhythm EKG) is a column II code 
with a modifier indicator of 0 when billed with column I code 99291 (critical care, first hour) and is not 
separately payable; however, there are no active National Correct Coding Initiatives (NCCI) procedure-to-
procedure (PTP) edits for these codes. The Plan has not provided any documentation to support that code 
93042 is not payable as billed. Therefore, we decided that the Plan has to pay for the rhythm electrocardiogram 
(EKG) rendered on August 12, 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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided to the enrollee on July 28, 2021. 
 
You asked the Plan to pay for these services. You say that these services should be covered by the Plan.  The 
Plan denied your request. The Plan says these services must be reviewed by Original Medicare first and present 
an explanation of benefits to the Plan before the Plan can review.  
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for medical services provided to the enrollee on July 28, 2021.