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

 
We decided that the Plan does not have to pre-approve a transthoracic echocardiography (TTE) (93306). 
 
You asked the Plan to pre-approve a TTE. You say that you would like authorization to be approved for this 
service. The Plan denied your request. The Plan says this request is not medically necessary per Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a TTE. Our reviewer says that a 
transthoracic echocardiography is not considered medically reasonable and necessary in this case. Our 
physician reviewer found documentation would not point to a change in status that would support the medical 
necessity of a repeat TTE at this time. Clinical guidelines do not support repeating a TTE with no intervening 
change in clinical status or new signs, symptoms or physical findings. Our reviewer also found that there is no 
supportive evidence for the medical necessity of a TTE in 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 TTE have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a transthoracic echocardiography (TTE) (93306).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on September 8, 2021. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. 
 The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory 
testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
September 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on June 6, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. 
 The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory 
testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on June 6, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation - new or established patient 
(D0150), intraoral - complete series of radiographic images (D0210), resin-based composite - two surfaces, 
posterior (D2392), crown - porcelain fused to high noble metal (D2750) and core buildup, including any pins 
when required (D2950) provided on August 24, 2022, to September 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that all the services that were provided should be 
covered by your plan. The Plan denied your request. The Plan says your benefit for the requested item or 
service 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. This benefit includes the 
requested comprehensive oral evaluation - new or established patient (D0150), intraoral - complete series of 
radiographic images (D0210) but each is limited to one procedure every three plan years. Resin-based 
composite - two surfaces, posterior (D2392), crown - porcelain fused to high noble metal (D2750) and core 
buildup, including any pins when required (D2950) are not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested comprehensive oral evaluation - new or established patient (D0150), 
intraoral - complete series of radiographic images (D0210) was exhausted on date of service June 4, 2020. 
Resin-based composite - two surfaces, posterior (D2392), crown - porcelain fused to high noble metal (D2750) 
and core buildup, including any pins when required (D2950) are not covered under the Plans dental benefits. 
Therefore, we decided that the Plan does not have to pay for comprehensive oral evaluation - new or 
established patient (D0150), intraoral - complete series of radiographic images (D0210), resin-based composite 
- two surfaces, posterior (D2392), crown - porcelain fused to high noble metal (D2750) and core buildup, 
including any pins when required (D2950) provided on August 24, 2022, to September 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on August 8, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. 
 The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory 
testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on August 
8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
(87801, 87798, 87481, and 87150) provided on December 17, 2021. 
 
You asked the Plan to pay for the urine PCR testing. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the PCR testing is considered unproven and not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that [insert custom text from glossary].  
 
We looked at the file and Medicare rules. The file shows that the services at issue exceeded the standard of care 
for the diagnosis and treatment of a UTI. Based on this information, we decided that Medicare rules for 
coverage of the urine PCR testing have not been met. Therefore, we decided that the Plan does not have to pay 
for the urine polymerase chain reaction (PCR) panel testing (87801, 87798, 87481, and 87150) provided on 
December 17, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for x-rays and an ultrasound provided on June 
15, 2022. 
 
You asked the Plan to waive the copayments for x-rays and an ultrasound. You say that this should be covered. 
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 $10 
copayment for Medicare-covered x-rays and a $100 copayment for an ultrasound.  
 
 
 
 You have been asked to pay a total of a $110 copayment for x-rays and an ultrasound. These items/services fall 
within the Outpatient diagnostic tests and therapeutic services and supplies 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 copayments for x-rays and an ultrasound provided on June 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing - four or more teeth per 
quadrant (D4341) provided on October 6, 2022, to October 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that you do not agree with the denial, and you hope 
the insurance will cover the services. The Plan denied your request. The Plan says the dental services were 
received from an out-of-network provider and are not covered by your supplemental benefits. 
 
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 record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for periodontal scaling and root planing - four or more teeth per quadrant (D4341) provided on October 
6, 2022, to October 13, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided from July 15, 2022, to August 13, 2022. 
 
You asked the Plan to pay for SNF care. You say that the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says skilled nursing facility services 
are no longer required 
 
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 pay for 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 that the enrollee did not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing 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 pay for SNF care provided from July 15, 2022, to August 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on August 11, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. 
 The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory 
testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on August 
11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ,periodontal scaling and root planing - four or more teeth per 
quadrant (D4341), and periodontal scaling and root planing - one to three teeth per quadrant (D4342) provided 
on August 5, 2022, and August 8, 2022. 
 
You asked the Plan to pay for the periodontal scaling and root planing - four or more teeth per quadrant 
(D4341), and periodontal scaling and root planing - one to three teeth per quadrant (D4342). You say that you 
are appealing the denied payment for the rendered dental services. The Plan denied your request. The Plan says 
these services are not covered under the benefit package. 
 
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 
periodontal scaling and root planing - four or more teeth per quadrant (D4341), and periodontal scaling and 
root planing - one to three teeth per quadrant (D4342) provided on August 5, 2022, and August 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on August 3, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. 
 The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory 
testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on August 
3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair (PWC) repairs. 
 
You asked the Plan to pre-approve these services. You say that the services are needed for the enrollee's care. 
The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that the cost of repairs must not cost more than 
replacement equipment. 
 
We looked at the file and Medicare rules. The file shows that the requested repairs would cost more than a 
replacement PWC. 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 power wheelchair (PWC) 
repairs.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda (J9271). 
 
You asked the Plan to pre-approve Keytruda. You say that the enrollee is progressing in their disease, and are 
adamant for this treatment. The Plan denied your request. The Plan says the clinical value and effectiveness of 
Keytruda in the setting of Microsatellite-stable and/or a low tumor mutational burden have not been 
demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Keytruda. Our reviewer says that the 
elements of the coverage criteria are not satisfied, and the requested service cannot be recommended. Our 
physician reviewer found the record indicates that the enrollee has a diagnosis of malignancy of the pancreatic 
head. The record provided is insufficient to establish whether the elements of the coverage criteria for the 
requested drug are satisfied. Our reviewer found that the FDA has not stated that the requested drug is indicated 
for the enrollee's condition. The Medicare approved cancer drug compendia do not contain a supportive citation 
for the use of the requested drug in the enrollee's clinical situation. Our physician reviewer also found that no 
literature from Medicare approved cancer journals were submitted for review.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda (J9271).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental exam (D0120) and a dental cleaning (D1110) 
provided on August 25, 2022. 
 
You asked the Plan to pay for the dental services. You say that no one has gone over your benefits with you, 
and you do not need another dentist assigned to you. The Plan denied your request. The Plan says for services 
to be covered, you must receive dental care from your assigned dentist. 
 
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, services not received by your assigned 
dentist are not covered. Therefore, we decided that the Plan does not have to pay for a dental exam (D0120) 
and a dental cleaning (D1110) provided on August 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 12, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on July 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 2D oral/facial photographic image obtained intra-orally or 
extra-orally (D0350) x2 provided on September 6, 2022. 
 
You asked the Plan to pay for dental services. You say that you would like the provided service covered by 
insurance. The Plan denied your request. The Plan says this service is not covered under your 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. 2D oral/facial photographic 
image obtained intra-orally or extra-orally (D0350) x2 is not covered under the Plans dental benefits. 
 
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 2D 
oral/facial photographic image obtained intra-orally or extra-orally (D0350) x2 provided on September 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home delivered prepared meals. 
 
You asked the Plan to pre-approve the home delivered prepared meals. You say that you are asking for the 
post-discharged meals. The Plan denied your request. The Plan says your request is denied because the 
authorization request was not received within the 14 calendar days of discharge home after your hospital stay. 
 
The Plan must follow Medicare rules. The rules say that the Plan may offer meals as a supplemental benefit 
immediately following surgery or an inpatient hospital stay, or for certain chronic conditions. The Plan offers 
home-delivered meals supplemental benefit. The Plan covers home-delivered meals after discharge from a 
hospital or skilled nursing facility if authorization is received with the 14 days of discharge. 
 We looked at the file and Medicare rules. While you were discharged from an inpatient hospital stay, 
authorization was not received within 14 days of your discharge. Based on this information, we decided that 
Medicare rules for coverage of the home delivered prepared meals have not been met. Therefore, we decided 
that the Plan does not have to pre-approve home delivered prepared meals.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
August 9, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service August 9, 2022.