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

 
We decided that the Plan does not have to waive the copayment for urgent care services provided on November 
9, 2021. 
 
You asked the Plan to waive the copayment for urgent care services. You say that you never received any 
services so you shouldn't be charged. The Plan denied your request. The Plan says the copayment applied is 
correct. 
 
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 $30 
copayment for each visit in a contracted Urgent Care Center or walk-in clinic.  
 
You have been asked to pay $30 copayment for urgent care services. Urgent care services fall within the 
Urgently Needed Services 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 urgent care 
services provided on November 9, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued SNF services.

You asked the Plan to pre-approve continued SNF. You say that you need continued SNF care. The Plan denied your request. The Plan says the enrollee does not meet criteria for continued SNF services after July 30, 2022.

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. Our physician reviewer found daily skilled services are not necessary after July 30, 2022. Our physician reviewer found that the medical records do not document that you require services on an inpatient basis, only in a skilled nursing facility.

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 have not been met. Therefore, we decided that the Plan does not have to pre-approve continued SNF services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 2, 2021 billed with 
codes 81201 and 81203. 
 
You asked the Plan to pay for the genetic testing billed. You say that You request reconsideration of this 
determination and coverage of the Tempus Gene Panel test at the in-network benefit level. The Plan denied 
your request. The Plan says correct coding requires that when a panel code is ordered, it should be billed, rather 
than the individual gene codes. 
 The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
June 2, 2021 billed with codes 81201 and 81203.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on November 15, 2021. 
 
You asked the Plan to pay for the services provided. You say that there is no agreement that the codes billed 
are included in the dialysis rate. The Plan denied your request. The Plan says the testing is not separately 
reimbursable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab 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 lab services provided on November 15, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a trial of a spinal cord stimulator (63650). 
 
You asked the Plan to pre-approve a trial of a spinal cord stimulator. You say that the requested service is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says that medical necessity rules for 
coverage of the requested service have not been met. 
 
The Plan follows Medicare rules. The rules say that no payment may be made for the implantation of dorsal 
column or depth brain stimulators or services and supplies related to such implantation, unless all of the 
conditions listed in the Medicare rules section 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 a trial of a spinal cord stimulator. Our 
reviewer says that the requested service is medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee has trialed other treatment modalities. The enrollee was seen by a psychologist 
and cleared for a trial. The enrollee meets coverage criteria for a spinal cord stimulator trial. 
 
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 trial of a spinal cord stimulator have been met. Therefore, we decided that the 
Plan has to pre-approve a trial of a spinal cord stimulator (63650).  
 
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 Krystexxa for the enrollee. 
 
You asked the Plan to pre-approve Krystexxa. You say that this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says that records do not show that the enrollee has tried at least 1 of the 
alternative drugs and that it did not help. 
 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 Krystexxa. Our reviewer says that 
Krystexxa is not medically reasonable and necessary. The Plan requires a 3 month trial of allopurinol, Uloric or 
a uricosuric agent with persistent increase in uric acid levels before they will approve the requested drug. In 
this case, the patient has not tried and failed the required drugs. There is no documentation provided indicating 
that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. 
Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Krystexxa. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Krystexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Krystexxa for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for wound care provided on September 27, 
2021, to October 28, 2021. 
 
You asked the Plan to waive the copayments for wound care. You say that these were billed incorrectly, and 
the enrollee shouldn't owe this amount. The Plan denied your request. The Plan says the copayment applied are 
correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay $250 copayment for Medicare covered surgery, provided at an outpatient hospital facility or 
ambulatory surgical center.  
 
 
 The enrollee has been asked to pay $1,211.90 ($242.38 x 5 visits) copayment for wound care. The enrollee has 
been asked to pay $242.38 per visit which is less than the standard $250 copayment for wound care. Wound 
care falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers benefit category. This means that the enrollee has been asked to pay the correct 
amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to 
pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for 
wound care provided on September 27, 2021, to October 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endodontic therapy on tooth #12 (D3320) provided on 
February 2, 2022. 
 
You asked the Plan to pay for endodontic therapy. You say that you were unaware that this service was not 
covered. The Plan denied your request. The Plan says endodontic therapy (D3320) is not covered by your 
supplemental dental 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. 
 
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 
endodontic therapy on tooth #12 (D3320) provided on February 2, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the use of i-FACTOR allograft (22853) in a spinal 
surgery. 
 
You asked the Plan to pre-approve i-FACTOR allograft. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for coverage 
have not been met because the requested services are experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve i-FACTOR allograft. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that i-FACTOR allograft is experimental. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of i-FACTOR allograft have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the use of i-FACTOR allograft (22853) in a spinal surgery.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an expandable control system. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says that the 
enrollee is able to control the power options thru their own switches. 
 
The Plan follows Medicare rules. Medicare rules say that wheelchair options and accessories are only covered 
under certain medical indications. 
 
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 requested services. Our physician 
reviewer found that the enrollee has a past medical history of T6 spinal cord injury with spasticity, neurogenic 
bladder and autonomic dysfunction with mobility and autonomic dysreflexia impairments. The clinical 
documentation lists multiple reasons why an expandable control system would be required including poor 
range of motion of the upper limbs, autonomic dysreflexia with access maybe restricted depending on 
positioning. Therefore, an expandable controller is medically necessary 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 the requested services have been met. Therefore, we decided that the Plan has to 
pre-approve an expandable control system.  
 
 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the notes do not show that the enrollee needs daily rehabilitation 
therapy 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 services. Our reviewer says that 
SNF services are not medically reasonable and necessary. Clinical documentation states that patient has 
multiple medical comorbidities and would require assessment and treatment by skilled nursing including PEG 
and trach care. It is documented that patient is unresponsive and there are no skilled therapy needs from a 
functional standpoint. Care team recommends unskilled care after discharge and there is no documentation as 
to why patient would require daily skilled nursing. Our physician reviewer found that the enrollee's condition 
does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that this is medically necessary 
for the enrollee's condition. The Plan denied your request. The Plan says the documentation does not support 
that the criteria for coverage have been met. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
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 pneumatic compression device. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found that the provided 
records do not clearly document the trial and failure of at least four weeks of regular, daily, multiple-hour home 
usage of an E0650 or E0651 pump after careful, in-person fitting, training and supervision by a technician who 
is skilled in and who regularly and successfully uses the appliance provided. 
 
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 PCD have not been met. Specifically, the record does not show that the 
enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after 
careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and 
successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a 
pneumatic compression device (E0652).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for vision services provided on February 22, 
2022. 
 
You asked the Plan to waive the deductible for vision services. You say that this service should be covered. 
The Plan denied your request. The Plan says the deductible 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 $203 deductible which applies to vision services.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category Vision 
Services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $203 
deductible which applies to vision services. This cost sharing is a contractual obligation that had not been met 
at the time vision services was received on February 22, 2022. Therefore, we decided that the Plan does not 
have to waive the deductible for vision services provided on February 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam and determination of refractive state provided 
on April 14, 2022. 
 
You asked the Plan to pay for the eye exam and determination of refractive state. You say that you had these 
services rendered for your yearly exam. You also say that you believe previously part of your eye exam was 
covered, and you believed you would have coverage with this provider going forward. The Plan denied your 
request. The Plan says these services were rendered by a non-participating provider without prior authorization. 
 
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 did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the eye exam and determination of refractive state 
provided on April 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a resin-based composite-two surfaces, posterior 
(D2392). 
 
You asked the Plan to pre-approve the resin-based composite. You say that you cannot afford the upgraded 
coverage. The Plan denied your request. The Plan says you have coverage for preventive dental only. 
 
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 pre-approve a 
resin-based composite-two surfaces, posterior (D2392).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the debridement of nails provided on March 2, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the debridement of nails. You say that the service was provided to the enrollee, 
and you would like the claim reprocessed. The Plan denied your request. The Plan says the rendering provider 
is an OON provider and there was no referral from an in-network provider or an approved authorization. Also, 
the service rendered was not urgent or emergent. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the debridement of nails provided on March 2, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gastroenterology services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that you did not like the way you were treated 
previously. The Plan denied your request. The Plan says the services are available within the 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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
gastroenterology services to be provided by an out-of-network (OON) provider.