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

 
We decided that the Plan does not have to pay for the surgical services provided on July 21, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you chose this provider due to his quality of work 
even though he is not in-network. The Plan denied your request. The Plan says the services were rendered by 
an out-of-network 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 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 surgical services provided on July 21, 2021 by 
an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 implant supported retainer crowns (D6076), and 2 
implant supported crowns (D6066). 
 
You asked the Plan to pre-approve implant supported retainer crowns and implant supported crowns. You say 
that you were advised previously that this was a covered service. You say that now that you have the implants 
placed, the coverings are being denied. You also say that these services should be approved. The Plan denied 
your request. The Plan says the requested services are not listed as covered. 
 
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 implant supported 
retainer crowns and implant supported crowns are not among those covered under this benefit. Therefore, we 
decided that the Plan does not have to pre-approve 8 implant supported retainer crowns (D6076), and 2 implant 
supported crowns (D6066).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the CT scan received on December 10, 
2021. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you've never been charged for a CT 
scan before. The Plan denied your request. The Plan says the copayment was applied 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 $200 
copayment for Medicare-covered diagnostic radiology services (i.e., MRI, CT, PET Scans, fluoroscopic-guided 
imaging, nuclear medicine).  
 
 
  You have been asked to pay the allowed amount of $162.92 for the CT scan, which is less than the standard 
$200 copayment. The CT scan 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 the CT scan received on 
December 10, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paring or cutting of benign hyperkeratotic lesion (eg, 
corn or callus) (11056) provided November 12, 2021. 
 
You asked the Plan to pay for the routine foot care. You say that please see attached medical records to support 
the claim. Please review and process the claim accordingly. The Plan denied your request. The Plan says the 
records do not show that the enrollee has any underlying diabetes or systemic disease, such as metabolic, 
neurologic, or peripheral vascular disease, therefore the service is not covered. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is 
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or 
feet or have fungal nails.  
 
Records do not show that any of these conditions are present. The services you are asking the Plan to pay for 
are routine foot care services. Based on this information, we decided that Medicare rules for coverage of the routine foot care have not been met. Therefore, we decided that the Plan does not have to pay for the paring or 
cutting of benign hyperkeratotic lesion (eg, corn or callus) (11056) provided November 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2332) provided by a participating 
provider on January 11, 2022. 
 
You asked the Plan to pay for a resin-based composite. You say that you would like the Plan to pay for this. 
The Plan denied your request. The Plan says the services provided are not covered. 
 
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 a resin-
based composite (D2332) provided by a participating provider on January 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services provided on April 13, 2021, by an 
out-of-network provider. 
 
You asked the Plan to pay for the out-of-network services. You say that you are appealing for reconsideration 
of the denied charges. The Plan denied your request. The Plan says this provider is out-of-network, the services 
were not referred by a network provider, and the services were not urgent or emergent, nor were they approved 
in advance. 
 
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 anesthesia services provided on April 13, 
2021, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the liners for commode. 
 
You asked the Plan to pre-approve the liners for commode. You say that the liners for commode are necessary. 
The Plan denied your request. The Plan says the liners for commode are not primarily medical and nature and 
excluded by Health Plan and Original Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. 
This item is available to the general public and would be helpful even to those who are not sick or injured. 
Therefore, we decided that the Plan does not have to pre-approve the liners for commode.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair (pw) expandable controller upgrade 
(E2377), a pw access harness upgrade (E2313), a power seat elevation system (E2300), a pw accessory, 
electronic connection between wheelchair controller and two or more power seating system motors (E2311), a 
pw accessory, attendant control (E2331), an adjustable height joystick bracket (K0108), a 6 inch footplate 
outside edge (K0108), a footrest width extension (K0108), arm stops (K0108), an egg switch (K0108) and an 
incontinent liner (K0108). 
 
You asked the Plan to pre-approve power wheelchair accessories. You say that the medical documentation 
proves the medical need for all features and accessories. Safety is at risk as you are a new spinal cord injury 
resulting in quadriplegia. Without the requested equipment, you are at high risk of skin breakdown/pressure 
sores that could lead to infection, hospitalization or more. The Plan denied your request. The Plan says the 
requested items are not covered with your Plan. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that a power seat elevation system is not primarily in nature and not covered. The file also 
shows that an attendant control cannot be covered in addition to an operated joystick which was approved by 
the Plan. The file also shows that all other denied accessories are upgraded electronics and are not covered 
items. The adjustable height joystick bracket, egg switch, footplate and extension, arm stops, seat liners are 
unbundled as they are already included. Therefore, we decided that the Plan does not have to pre-approve a 
power wheelchair (pw) expandable controller upgrade (E2377), a pw access harness upgrade (E2313), a power 
seat elevation system (E2300), a pw accessory, electronic connection between wheelchair controller and two or 
more power seating system motors (E2311), a pw accessory, attendant control (E2331), an adjustable height 
joystick bracket (K0108), a 6 inch footplate outside edge (K0108), a footrest width extension (K0108), arm 
stops (K0108), an egg switch (K0108) and an incontinent liner (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pulp vitality test (D0460 x 2), periapical x-ray (D0220), 
limited oral evaluation (D0140), retreatment of root canal (D3348), and filling (D2391) provided from 
November 17, 2021, to February 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that you have had multiple visits at this office. You 
also say that you were not aware they were out of network until now. The Plan denied your request. The Plan 
says dental services received out of network are not 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, 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 pulp vitality test (D0460 x 2), periapical x-ray (D0220), limited oral evaluation (D0140), retreatment of root 
canal (D3348), and filling (D2391) provided from November 17, 2021, to February 2, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Injectafer (J1439). 
 
You asked the Plan to pre-approve Injectafer. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says step therapy rules for the requested drug 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 Injectafer. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires a trial of drugs Infed and Venofer before they will approve the requested drug, Injectafer. Based 
on the medical records provided, the enrollee has tried Venofer but there is no indication that the enrollee has 
tried and failed Infed. There is no indication that Infed 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 Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Injectafer (J1439).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (88305, 88312) rendered by the out-
of-network (OON) provider on December 28, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the laboratory services (88305, 88312) rendered by the out-of-network (OON) 
provider on December 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that the requested drug is medically necessary and has 
labelled approval in relapsed/refractory cutaneous squamous cell skin cancer. You say that it has been 
demonstrated that patients who were treated with immunotherapy and failed can be retreated with 
immunotherapy after other agents which may have created an immune environment more conducive to cytoxic 
T cell stimulation. The Plan denied your request. The Plan says medical studies haven't proven that the 
requested drug is helpful, after having already tried the drug without a positive response. 
 
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 
criteria for coverage have not been met. Our physician reviewer found the enrollee has progressed on Keytruda 
and rechallenge is not reasonable and necessary. Our physician reviewer found that there is no literature to 
support the continuation of Keytruda past progression in nasopharynx.  
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.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient acne surgery (10040) provided January 28, 
2022. 
 
You asked the Plan to pay for the outpatient services. You say that the surgical procedure that was done was 
not cosmetic. It was done because it was irritating and bothersome and sometimes hurtful. The Plan denied 
your request. The Plan says cosmetic surgery or procedures are excluded and not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the outpatient services have not been met. Therefore, we decided that the Plan does not have to pay 
for the outpatient acne surgery (10040) provided January 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interspinous spacer placement (22869). 
 
You asked the Plan to pre-approve the interspinous spacer placement. You say that this service is medically 
necessary. The Plan denied your request. The Plan says the requested procedure is experimental and non-
covered. 
 
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 interspinous spacer placement. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found interspinous spacers are considered experimental. More research is needed to 
show safety and efficacy. 
 
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 interspinous spacer placement have not been met.  
 
 Therefore, we decided that the Plan does not have to pre-approve an interspinous spacer placement (22869).
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the esophagogastroduodenoscopy (43239), brush wash (43235), and 
diagnostic sigmoidoscopy (45330) provided on January 5, 2021. 
 
You asked the Plan to pay for the surgical services. You say that the services should be covered. The Plan 
denied your request. The Plan says that it is the providers responsibility to bill the Primary Group Health Plan 
or any liability insurance before submitting the claim to the enrollees plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the file shows that the claim was sent to the enrollees primary 
insurance. Therefore, we decided that the Plan has to pay for the esophagogastroduodenoscopy (43239), brush 
wash (43235), and diagnostic sigmoidoscopy (45330) provided on January 5, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Low Dose Computed Tomography (LDCT) for lung 
cancer screening. 
 
You asked the Plan to pre-approve a LDCT for lung cancer screening. You say that the services are necessary. 
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan follows Medicare rules. Medicare rules say that a LDCT for lung cancer screening is covered when 
specific criteria 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 a LDCT for lung cancer screening. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the records indicate 
that the enrollee has a single pulmonary nodule and is therefore not asymptomatic. The elements of the 
coverage criteria are not satisfied. The requested service cannot be recommended.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a LDCT for lung cancer screening have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Low Dose Computed Tomography (LDCT) for lung cancer 
screening.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure (CPT code 64628). 
 
You asked the Plan to pre-approve the intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says unproven and not medically necessary procedures are not covered by 
Medicare due to insufficient evidence of efficacy. 
 
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 intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation does not support actual formal surgical ablation of pre-designated 
basivertebral nerves as being medically necessary and/or reasonable at this time. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. Therefore, the requested intracept intraosseous basivertebral nerve ablation at L5 and S1, in this 
case, 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 intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the intracept procedure (CPT code 64628).
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a GeneSight gene panel. 
 
You asked the Plan to pre-approve a GeneSight gene panel. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or 
provider must corroborate the documentation in the enrollee's medical records and confirm that Medicare 
coverage criteria have been met. 
 
We looked at the file and Medicare rules. Specifically, medical records were not provided. Without this 
documentation, medical necessity is not able to be established. Based on this information, we decided that 
Medicare rules for coverage of a GeneSight gene panel have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a GeneSight gene panel.