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

We decided that the Plan does not have to pre-approve Botox injections (J0585) to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve Botox injections. You say that this provider has been covered in the past. 
The Plan denied your request. The Plan says this is available 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 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 
Botox injections (J0585) to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the ConfirmMDx testing rendered on April 6, 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 the testing is not covered. 
 
The Plan must follow Medicare rules. The rule say that ConfirmMDx is covered for males aged 40 to 85 years 
old that have undergone a previous cancer-negative prostate biopsy within 24 months and are being considered 
for a repeat biopsy. 
 
We looked at the file and Medicare rules. The file shows that the enrollee was not being considered for a repeat 
biopsy. 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 ConfirmMDx testing rendered on April 6, 
2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve knee replacement (27446, 27447) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the medical office did not provide an x-ray or imaging to support 
the request. 

The Plan follows Medicare rules. Medicare rules say that knee replacement is covered if the LCD criteria have 
been 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 these services. Our reviewer says that 
these services are not medically reasonable and necessary for the enrollee. Detailed documentation is not 
evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care 
measures. The enrollee is noted to have tried physical therapy as well as injections. However, the type of 
injection tried and failed is not documented. The date range in which the conservative treatment had been 
trialed is also not evident. In addition, there was an x-ray noted on the October 7, 2021. However, the formal 
report was not provided for review to corroborate significant pathology that would require surgical 
repair/correction. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Our physician reviewer found that the enrollee's condition 
does not meet Medicare criteria for these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve knee replacement (27446, 27447) for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services you received on April 
10, 2021, and April 15, 2021. 
 
You asked the Plan to waive the copayment for the ambulance services. You did not provide an argument in 
your appeal request. The Plan denied your request. The Plan says you were charged these copayments 
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 $250 
copayment for each ambulance stabilization when there is no transport.  
 
You have been asked to pay a $250 copayment for the ambulance services. We looked at the records from 
these two dates. On each date, the ambulance arrived and evaluated you, but you refused transport to the 
hospital.  That is why each of these dates of service falls within the ambulance stabilization when there is no 
transport 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 ambulance services you 
received on April 10, 2021, and April 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to 
the enrollee on April 28, 2021. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says this should be reported with CPT 81479. 
 
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. 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 Comprehensive Genomic Profile (CGP) testing provided to the enrollee on April 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Armodafinil. 
 
You asked the Plan to pre-approve Armodafinil. You say that this drug could provide additional benefit. The 
Plan denied your request. The Plan says this drug is not covered for the enrollee's condition by Medicare Part 
B. 
 
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 Armodafinil.  
 
 Benefits for Armodafinil 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two gingival irrigations (D4921 x2) provided on May 6, 
2021. 
 
You asked the Plan to pay for the gingival irrigations. You say that you have dental coverage. The Plan denied 
your request. The Plan says this service is not covered under your plan benefits. The Plan also says that your 
provider advised that you were informed this procedure would not be covered. 
 
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 two 
gingival irrigations (D4921 x2) provided on May 6, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One (J7326). 
 
You asked the Plan to pre-approve Gel-One. You say that this is supported by the records. 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 Gel-One. Our reviewer says that the 
requirements for coverage of Gel-One have not been met. Our physician reviewer found the Plan requires a 
trial of drug Monovisc and Orthovisc before they will approve the requested drug. The enrollee has not tried 
and failed Monovisc and Orthovisc. There is no documentation provided indicating 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 Gel-One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-One (J7326).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services represented by code 99100 provided 
on February 17, 2021. 
 
You asked the Plan to pay for code 99100. You say that you would like the Plan to reconsider their denial of 
payment. 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. 
 
We looked at the file and Medicare rules. Code 99100 has a status code of "B" under the Medicare Physicians 
Fee Schedule Database (MPFSDB) and no separate payment is made for this code under the fee schedule as 
payment is bundled into the payment for the services to which this code is incident to. Therefore, we decided 
that the Plan does not have to pay for the anesthesia services represented by code 99100 provided on February 
17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an excision of a lesion (D7410), inhalation of nitrous oxide (D9230), a comprehensive oral evaluation (D0150), and a panoramic radiographic image (D0330) provided by an out-of-network provider on March 14, 2019, to May 15, 2019.

You asked the Plan to pay for an excision of a lesion, inhalation of nitrous oxide, a comprehensive oral evaluation, and a panoramic radiographic image. You say that you called the Plan and asked what providers were in-network. The Plan denied your request. The Plan says this claim has been processed correctly.

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. The Plan covers an excision of a lesion, inhalation of nitrous oxide, a comprehensive oral evaluation, and a panoramic radiographic image when the services are medically necessary and reasonable.

We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of an excision of a lesion, inhalation of nitrous oxide, a comprehensive oral evaluation, and a panoramic radiographic image have not been met. Therefore, we decided that the Plan does not have to pay for an excision of a lesion (D7410), inhalation of nitrous oxide (D9230), a comprehensive oral evaluation (D0150), and a panoramic radiographic image (D0330) provided by an out-of-network provider on March 14, 2019, to May 15, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve esophagogastroduodenoscopy with esophagastric 
fundoplasty. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is considered experimental, investigational, and unproven. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found appropriate patient selection is crucial before anti-reflux procedures. You have only undergone the 
esophagogastroduodenoscopy (EGD) component of the pre-operative assessment. No data was presented that 
your lower esophageal sphincter (LES) requires augmentation, that you are refractory to acid suppression, nor 
that there is unequivocal correlation of heartburn with acid reflux events. Trans-oral incisionless fundoplication 
(TIF procedure) has shown merit and durable response for some GERD patients, but is not medically necessary 
for you. Further, the role of TIF in patients with Barrett's esophagus has not been fully investigated, and is the subject of ongoing study. This would be considered unproven and investigational. There are substantial 
complication and failure rates for this procedure. 
 
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 esophagogastroduodenoscopy with esophagastric fundoplasty.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the scanning computerized ophthalmic 
diagnostic imaging (SCODI) service you received on May 5, 2021. 
 
You asked the Plan to waive the copayment for the SCODI service. You say that you should have only paid 
your $45 copayment, not this additional $50 copayment.  You said that you have had this service in the past 
and never had to pay an additional copayment before. The Plan denied your request. The Plan says you were 
charged this copayment 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 $50 
copayment for diagnostic tests.  
 
You have been asked to pay a $50 copayment for the SCODI service. The SCODI service falls within the diagnostic tests benefit category. This copayment applies regardless of whether you have paid this in the past or 
not. 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 scanning computerized ophthalmic diagnostic 
imaging (SCODI) service you received on May 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that an LTACH is the most appropriate level 
of care for this patient. The Plan denied your request. The Plan says that the member is receiving appropriate 
in-patient acute care and does not require transfer to an LTACH. 
 
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. The enrollee 
is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the 
LTACH that are not available at the acute care hospital where she is currently receiving care. Our physician 
reviewer found that the enrollee's 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse you more for chiropractic services you received from an out-of-network chiropractor on November 30, 2020.
 
You asked the Plan to reimburse you more for the out-of-network chiropractic services. You say that in 
previous claims with this provider, you had been reimbursed the total you paid minus your copayment.  You do 
not understand why this claim was reimbursed differently. The Plan denied your request. The Plan says you 
were reimbursed correctly. 

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment for out-of-network chiropractic services. In addition, the rules say that this provider must accept the Medicare-allowed rate for services provided to you.
 
Records show that you received out-of-network chiropractic services on November 30, 2020. The provider billed procedure code 98941 for these services. According to Medicare rules, providers must accept the Medicare-allowed rate for services provided. In this case, the Medicare-allowed rate for procedure code 98941 is $41.98. The Plan subtracted your required out-of-network chiropractic copayment of $20 from this amount, resulting in the reimbursement amount of $21.98. The provider in this case has charged you more than they should have. You have the right to go back to the provider to request a refund of any amounts you paid above the Medicare-allowed rate of $41.98 because you are a Medicare Health Plan enrollee. This does not mean that the Plan is required to pay more for these services. Therefore, we decided that the Plan does not have to reimburse you more for chiropractic services you received from an out-of-network chiropractor on November 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove the Continuous Glucose Monitor (CGM). 
 
You asked the Plan to preapprove the CGM. You say that the enrollee requires the device. The Plan denied 
your request. The Plan says the enrollee does not meet coverage criteria. 
 
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 perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, or require frequent self-adjustment 
of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to preapprove the Continuous Glucose Monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a vehicle wheelchair lift. 
 
You asked the Plan to pre-approve a vehicle wheelchair lift. You say that you are pretty much home bound and 
that this car lift would be a big help for you. The Plan denied your request. The Plan says that this is not 
covered by Medicare or the Plan. 
 
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 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. Therefore, we decided that the Plan does not 
have to pre-approve a vehicle wheelchair lift.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmology services (99203, 92133) provided outside the 
United States on June 15, 2021. 
 
You asked the Plan to pay for the ophthalmology services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the services were provided outside the United States and were 
non-emergent.  
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
 
We looked at the file, and Medicare rules. The records do not show the service was of an emergent nature. 
Based on this information, we decided that Medicare rules for coverage of the ophthalmology services have not 
been met. Therefore, we decided that the Plan does not have to pay for ophthalmology services (99203, 92133) 
provided outside the United States on June 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), panoramic x-ray 
(D0330), surgical extraction (D7210), nitrous oxide (D9230), and simple extraction (D7140) provided from 
March 14, 2019, to May 15, 2019. 
 
You asked the Plan to pay for the dental services. You say that you were advised by a plan representative that 
the provider in this case was in network. You say that you called the plan again this year and were advised 
again that the dental office was in network, but no specific dentist. You also say that you never would have 
gone to an out of network dentist if you had known. The Plan denied your request. The Plan says the provider 
in this case is out of network. The Plan says that dental services received out of network are not covered. The 
Plan also says that they did not indicate that the dental office in this case was in network.  
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 dental services received out of 
network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for the comprehensive oral evaluation (D0150), panoramic x-ray (D0330), surgical extraction (D7210), 
nitrous oxide (D9230), and simple extraction (D7140) provided from March 14, 2019, to May 15, 2019.