Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) 
provided May 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that this service was necessary for treatment. 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 27, 2022. 
Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused 
(D0140) provided May 2, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the GTC (genomic testing cooperative) Liquid Biopsy, Solid Tumor 
(81455) provided on June 21, 2021. 
 
You asked the Plan to pay for GTC Liquid Biopsy, Solid Tumor testing. You say that this test was approved by 
the MolDX program and is medically necessary for this enrollee. The Plan denied your request. The Plan says 
that there are Medicare coverage determinations which indicate that panels including the FANCC and BLM 
genes are not covered. 
 
Medicare rules say that molecular diagnostic laboratory tests are subject to the MolDX application, assessment, 
and approval process. Once this is complete, the test is assigned a reimbursement rate and a unique test 
identifier. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as covered. This determination 
was made and is specific to the test at issue. Though this panel does include genes that another coverage rule 
indicates are non-covered, we find there is no basis to overrule the specific coverage decision made by the 
MolDx contractor for this particular test. Based on this information, we decided that Medicare rules for 
coverage of GTC Liquid Biopsy, Solid Tumor testing have been met. Therefore, we decided that the Plan has 
to pay for the GTC (genomic testing cooperative) Liquid Biopsy, Solid Tumor (81455) provided on June 21, 
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: Lab
Decision: Favorable

 
We decided that the Plan has to waive the copayment for the prostate specific antigen (PSA) test provided on 
January 17, 2022. 
 
You asked the Plan to waive the copayment for the laboratory testing. You say that this should be covered with 
no copay. The Plan denied your request. The Plan says that you have been charged the correct cost sharing 
amount. 
 
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 enrollees must pay $0 there is no coinsurance copayment, or deductible for an 
annual PSA test. for Prostate Cancer Screening Exams.  
 
The Plan says you must pay a $10 copayment per day for an outpatient diagnostic test. The records do not 
support that you have already received a PSA test in the Plan year. This means that the Plan has not supported 
this service was diagnostic in nature for a $10 copayment to apply. Based on the Plan contract, you cannot be 
asked to pay more than $0 for an annual PSA test. Therefore, we decided that the Plan has to waive the 
copayment for the prostate specific antigen (PSA) test provided on January 17, 2022.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the panoptic multifocal lenses for post-cataract surgery 
eyewear. 
 
You asked the Plan to pre-approve the panoptic multifocal lenses. You say that since the Plan is paying and not 
Medicare, you do not feel that Medicare rules are a valid denial reason. The Plan denied your request. The Plan 
says coverage can only be provided for items covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that progressive or specialty multifocal lenses are 
noncovered. 
 
We looked at the file and Medicare rules. The Plan does not offer a supplemental benefit that expands coverage 
for post-cataract surgery eyewear. Based on this information, we decided that Medicare rules for coverage of 
the panoptic multifocal lenses have not been met. Therefore, we decided that the Plan does not have to pre-
approve the panoptic multifocal lenses for post-cataract surgery eyewear.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits to be provided by an OON provider. 
 
You asked the Plan to pre-approve office visits. You say that the enrollee has had persistent symptoms of 
numbness/weakness in extremities. You say that the enrollee needs a tertiary neurology consultation. The Plan 
denied your request. The Plan says services are available with in-network providers. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
office visits to be provided by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on April 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told you could go to any dentist and 
submit for possible reimbursement. 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 dental services provided on April 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic manipulative treatment provided on June 28, 
2021. 
 
You asked the Plan to pay for chiropractic manipulative treatment. The Plan denied your request. The Plan says 
the only covered chiropractic service is manual manipulation of the spine.  
 
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.  
 
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 chiropractic manipulative treatment. Our 
reviewer says that the case file does not contain recent documentation supporting that additional chiropractic 
services are medically necessary per Medicare guidelines. Our physician reviewer also found that there is no 
recent documentation demonstrating a neuromuscular condition for which manual manipulation is medically 
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 chiropractic manipulative treatment have not been met. Therefore, we decided 
that the Plan does not have to pay for chiropractic manipulative treatment provided on June 28, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide services. 
 
You asked the Plan to pre-approve home health aide services. You say that home health aide services are 
medically necessary. The Plan denied your request. The Plan says home health aide are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 home health aide services. Our 
reviewer says that home health aide services are not medically necessary. Our physician reviewer found that 
the services do not meet the definition of home health aide services. The enrollee is not home bound. The home 
health aide services are not reasonable and necessary to the treatment of the enrollees illness or injury by the 
skilled professional staff. Other informal and non-skilled support could be utilized.   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health aide services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve home health aide services.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Genomic Testing Cooperative (GTC) Hematology Profile testing 
provided September 21, 2021. 
 
You asked the Plan to pay for the GTC Hematology Profile testing. You say that this test was approved by the 
MolDX program and is medically necessary for this enrollee The Plan denied your request. The Plan says that 
there are Medicare coverage determinations which indicate that panels including the FANCC and BLM genes 
are not covered 
 
The Plan must follow Medicare rules. Medicare rules say that [insert custom text from glossary].  
 
We looked at the file and Medicare rules. This test is listed in the DEX database as covered. This determination 
was made and is specific to the test at issue. Though this panel does include genes that another coverage rule 
indicates are non-covered, we find there is no basis to overrule the specific coverage decision made by the 
MolDx contractor for this particular test. Based on this information, we decided that Medicare rules for 
coverage of the GTC Hematology Profile testing have been met. Therefore, we decided that the Plan has to pay 
for the Genomic Testing Cooperative (GTC) Hematology Profile testing provided September 21, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory work provided on January 20, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory work. You say that the service was medically necessary. The Plan 
denied your request. The Plan says no prior authorization was obtained. 
 
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 
laboratory work. We found no exception that would require the Plan to pay for the laboratory work. The 
records provided for review do not show that the laboratory work was urgent or emergent. Therefore, we decided that the Plan does not have to pay for laboratory work provided on January 20, 2022, by 
an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission. 
 
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 care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee is status post elective left hip replacement. From a nursing perspective, 
the enrollee received oral medications. The enrollee had stable vital signs. She was treated for pain. Regarding 
rehabilitation services, the enrollee received physical therapy and occupational therapy. The enrollee was at a 
maximal assist level for bed mobility and was able to transfer and ambulate short distances with stand by assist 
to contact guard assist. The enrollee required varying assist with activities of daily living.  
 
There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The 
enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet 
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lift recliner (E1399) purchased April 22, 2022 from an 
out of network supplier. 
 
You asked the Plan to pay for the lift recliner. You say that you purchased this item so the enrollee could come 
home from the rehab center. The equipment was only available at the place you got it from. The Plan denied 
your request. The Plan says if you go to a provider who is not eligible to participate in Medicare, you will be 
responsible for the full cost of the services you receive. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the lift recliner (E1399) purchased April 
22, 2022 from an out of network supplier.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Repatha Sureclick. 
 
You asked the Plan to pre-approve Repatha Sureclick. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested drug is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Repatha Sureclick.  
 
Benefits for Repatha Sureclick may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayment for an office visit for an eye examination provided on 
March 23, 2022. 
 
You asked the Plan to waive the copayment for the office visit for an eye examination. You say that the visit 
should apply to the vision benefit and no copay should be applied to the claim. The Plan denied your request. 
The Plan says that the claim was processed correctly as the provider did not bill with a vision office visit code. 
 
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 does not say in clear and accurate terms 
how much you should expect to pay for Vision Care, outpatient physician services for the diagnosis and 
treatment of diseases and injuries of the eye, including treatment for age-related macular degeneration.  
 
We looked at your contract with the Plan. We did not see where the contract says enrollees must pay a $50 
copayment for Vision Care, outpatient physician services for the diagnosis and treatment of diseases and 
injuries of the eye, including treatment for age-related macular degeneration. The Plan contract does not clearly 
say how much enrollees must pay for Vision Care, outpatient physician services for the diagnosis and treatment 
of diseases and injuries of the eye, including treatment for age-related macular degeneration. This means that 
the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that 
the Plan has to waive the copayment for an office visit for an eye examination provided on March 23, 2022.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 15, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that it was medically necessary to treat the enrollee and 
you would like the claim paid. The Plan denied your request. The Plan says the rendering provider is an OON 
provider and there was no 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 an office visit provided on April 15, 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 a resin-based composite filling on tooth #20 (D2391) 
provided on May 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that if is very difficult for you to pay for this service. 
The Plan denied your request. The Plan says the timeframe of six months to remake the original restoration was 
not met. 
 
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, certain limitations apply. The record 
shows the Plan paid for a filling on tooth #20 on date of service December 15, 2021. Therefore, we decided that 
the Plan does not have to pay for a resin-based composite filling on tooth #20 (D2391) provided on May 2, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided by an out-of-network 
provider on May 31, 2021, to June 3, 2021. 
 You asked the Plan to pay for inpatient hospital services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says the medical criteria for the inpatient services provided have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with A41.52 - sepsis due to pseudomonas, R65.20 - 
severe sepsis without septic shock, and J96.21 - acute and chronic respiratory failure with hypoxia as a 
principal diagnosis. 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 inpatient hospital services. 
Our reviewer says that the inpatient hospital admission was not medically necessary. Our physician reviewer 
found the clinical findings in the record do not sufficiently support the diagnosis of sepsis based on Sepsis 3 
criteria.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided by an out-of-network provider on May 31, 2021, to June 3, 2021.