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

 
We decided that the Plan does not have to pay for the drug testing (G0480, 80307) provided on September 17, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the drug testing. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing is not covered when provided OON 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 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 drug testing (G0480, 80307) provided on 
September 17, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the polycarbonate lens provided on May 20, 2022. 
 
You asked the Plan to pay for the polycarbonate lens. You say that you are appealing this denial. The Plan 
denied your request. The Plan says the service is not a covered benefit.  
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers basic lenses. 
 
We looked at the file and the Plan's rules. Specifically, the polycarbonate lens is not a covered service Based on 
this information, we decided that the Plan's rules for coverage of the polycarbonate lens have not been met. 
Therefore, we decided that the Plan does not have to pay for the polycarbonate lens provided on May 20, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a mammogram provided on October 18, 
2022. 
 
You asked the Plan to waive the coinsurance for a mammogram. You say that you disagree with the 
copayment. 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 a 20% 
coinsurance for outpatient diagnostic test/mammography.  
 
You have been asked to pay a 20% coinsurance for a mammogram. The total allowed amount for the 
mammogram is $118.09. The amount you are being asked to pay $23.62 ($118.09 x 20% = $23.62). This 
item/service falls within the outpatient diagnostic test/mammography 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 coinsurance for a mammogram provided on October 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for computed tomography (CT scan) provided 
on August 05, 2022. 
 
You asked the Plan to waive the copayment for computed tomography (CT scan). 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 a $300 
copayment for Advanced imaging services in an outpatient hospital. 
 
You have been asked to pay a $300 copayment for computed tomography (CT scan). This item/service falls 
within the Advanced imaging services in an outpatient hospital 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. You have been asked to pay $128.12 which is less 
than the standard $300 copayment for a CT scan. Therefore, we decided that the Plan does not have to waive 
the copayment for computed tomography (CT scan) provided on August 05, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on October 20, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration for 
payment. 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 the dental services on October 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) provided on September 28, 2022, at a 
chiropractic office. 
 
You asked the Plan to pay for the evaluation and management service. You say that had you known you would 
be billed for the office visit then you would not have gone. The Plan denied your request. The Plan says this 
service is not covered when rendered in a chiropractic office. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99202) provided on September 28, 2022, at a chiropractic 
office.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve psychological and neuropsychological testing. 
 
You asked the Plan to pre-approve psychological and neuropsychological testing. The Plan denied your 
request. The Plan says it is not clear from the records what the medical necessity of the testing is given that 
initial lab work and imaging has been ordered. The Plan also says it is not clear how psychological testing will 
change care or treatment plan. 
 
The Plan follows Medicare rules. Medicare rules say that the medical record must indicate the presence of 
mental illness or signs of mental illness for which psychological testing is indicated as an aid in the diagnosis 
and therapeutic planning. The record must show the tests performed, scoring and interpretation, as well as the 
time involved. 
 
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 psychological and neuropsychological 
testing. Our reviewer says that psychological and neuropsychological testing is not medically reasonable and 
necessary for you. Our physician reviewer found the documentation shows you claim to be having memory 
impairment, although there is no documentation in the neurologic exam notes that were presented. Our 
reviewer also found that you do not meet the criteria for coverage as you are not showing severity of symptoms 
that would warrant this type of diagnostic treatment, and is therefore not medically necessary or reasonable as 
the outcome of testing will not impact your treatment. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of psychological and neuropsychological testing have not been met. Therefore, we 
decided that the Plan does not have to pre-approve psychological and neuropsychological testing.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate services. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
clinical effectiveness has not been demonstrated. 
 
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 requested services. Our physician 
reviewer found that the enrollee is being treated for spinal stenosis of the lumbar region without neurogenic 
claudication. The Plan approved the inpatient L1-2 extreme lateral interbody fusion and posterolateral fusion 
with posterior instrumentation. However, there is no specific indication provided to support the request for 
bone marrow aspirate for the approved surgery.  There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of bone marrow 
aspirate for this enrollees medical condition as discussed above. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the 
request for is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomographic (CT) colonography screening 
(74263). 
 
You asked the Plan to pre-approve a CT colonography screening. You say that in 2017 a complete colonoscopy 
with a pediatric colonoscope was performed. You also say that the enrollee was unable to complete the 
colonoscopy with the previous techniques used. The Plan denied your request. The Plan says the requested 
screening CT Colonography is a nationally non-covered test. 
 
The Plan must follow Medicare rules. Medicare rules say that a screening computed tomographic colonography 
(CTC) is non-covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a CT colonography screening have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomographic (CT) colonography screening (74263).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lupron Depot (J9217). 
 
You asked the Plan to pre-approve Lupron Depot. You say that you do not and will not carry Eligard, and you 
would like the enrollee to be approved for Lupron. The Plan denied your request. The Plan says Lupron Depot 
is a non-preferred product, and the enrollee does not have any stated contraindications to the preferred 
products. The Plan also says the enrollee has not tried any of the preferred agents, and the provider does not 
provide a rationale for 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 Lupron Depot. Our reviewer says that 
the enrollee does not meet the criteria for coverage for Lupron Depot. Our physician reviewer found the Plan 
requires a trial of Eligard before they will approve the requested drug. In this case, the enrollee has not tried 
and failed the required drug. Our reviewer also found that there is no documentation provided indicating that 
the Plans 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 Lupron Depot have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Lupron Depot (J9217).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on July 12, 2022. 
 
You asked the Plan to pay for laboratory services. You say that this is supported by the records. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory services 
provided on July 12, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says admission to an IRF is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the documentation does not support the necessity for admission to an IRF due to 
the lack of medical or rehabilitation complexity and acute rehabilitation nursing needs. While the enrollee may 
have a need for physical therapy and/or occupational therapy, the enrollee's rehabilitation needs can be provided in a lower intensity and alternate setting such as in-home with continued services or in an SNF with 
intermittent 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre Sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre Sensor. You say that you have been using the Freestyle 
Libre effectively and successfully for almost three years and are appealing for consideration to continue. The 
Plan denied your request. The Plan says if you are not on insulin at least three times a day and changing the 
insulin dose based on your most recent blood glucose, Medicare does not cover continuous glucose monitors 
(CGMs) or CGM supplies. 
 
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 you do not 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 a Freestyle Libre Sensor 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre Sensor.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pulmonary ventilation and duplex venous imaging 
provided on August 7, 2022, billed with codes 78582 and 93970. 
 
You asked the Plan to pay for the pulmonary ventilation and duplex venous imaging. You say that the claim 
denied in error. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim 
and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on August 07, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the pulmonary ventilation and duplex venous imaging have not been met. Therefore, we decided that the Plan does not have to pay for the pulmonary 
ventilation and duplex venous imaging provided on August 7, 2022, billed with codes 78582 and 93970.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 You asked the Plan to pre-approve an epidural steroid injection. The Plan denied your request. The Plan says 
there was no documentation reviewed of failed conservative care of four weeks. The Plan also says there was 
no documentation intolerant to conservative care including. 
 
The Plan follows Medicare rules. Medicare rules say that an epidural steroid injection (ESI) will be considered 
medically reasonable and necessary when the three (3) requirements listed in the Medicare rules section of this 
letter 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 an epidural steroid injection. Our 
reviewer says that you do not meet the criteria for coverage for an epidural steroid injection. Our physician 
reviewer found you need a formal physical therapy (PT) consultation and trial. If this does not help or if the 
physician is concerned that the PT may be harmful, then that needs to be clearly documented. Our reviewer 
found that at this point however, there is no documentation of an adequate trial of conservative therapy and 
therefore, the request is deemed not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit and radiology services 
provided on September 13, 2022. 
 
You asked the Plan to waive the copayment for specialist office visit and radiology services. You say that you 
were only there one time to see the provider. 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 $35 in-
network copayment per day, per provider, for Medicare-covered x-ray services and $45 in-network copayment 
for each Medicare-covered visit with a specialist.   
 
  You have been asked to pay $80 for specialist office visit and radiology services ($35/x-ray + $45/specialist 
visit = $80). The specialist office visit falls within the physician/practitioner services, including doctor's office 
visits benefit category. The radiology services falls 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 copayment for specialist 
office visit and radiology services provided on September 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services billed for September 27, 2022. 
 
You asked the Plan to pay for the billed services. You say that medical records support the testing. The Plan 
denied your request. The Plan says the records do not support the coding criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code G0482 is definitive drug testing of 15-21 drug classes. 
We find that CPT code G0482 is not supported in the medical record. Specifically, the records do not show that 
15-21 drug classes were ordered or tested. Based on this information, we decided that Medicare rules for 
coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for 
the drug testing services billed for September 27, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ER visit provided on May 19, 2022. 
 
You asked the Plan to pay for ER visit. You say that this should be covered. The Plan denied your request. The 
Plan says the Original Medicare is responsible for payment. 
 
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 emergency room (ER) visit provided on May 19, 2022.