Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided as of June 15, 2022 at 
11:44AM, to June 19, 2022. 
 
You asked the Plan to pay for inpatient hospital care. You say that there is an unpaid balance on this claim. The 
Plan denied your request. The Plan says the enrollee condition had stabilized and the enrollee could have been 
transferred to an in-network facility. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval 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 pay for inpatient hospital care. Our reviewer says 
that this inpatient hospital care does not meet criteria for payment. Our physician reviewer found as of 
11:44AM on June 15, 2022 the enrollee was hemodynamically stable for ambulance transportation with 
monitoring to a Plan network facility for observation of admission. The treating physician did not document 
that the enrollee was unstable for transfer. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient hospital care have not been met. Therefore, we decided that the Plan 
does not have to pay for inpatient hospital care provided as of June 15, 2022 at 11:44AM, to June 19, 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 April 18, 2022. 
 
You asked the Plan to waive the copayment for computed tomography (CT scan). You say that since this was a 
cancer screening it 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 $150 
copayment for Diagnostic radiology services. 
 
You have been asked to pay a $150 copayment for computed tomography (CT scan). This item/service falls 
within the Diagnostic radiology 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. You have been asked to pay $136.90 which is less than the standard $150 
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 April 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight testing (81479) provided on March 14, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory testing. You say that this should be covered. The Plan denied your 
request. The Plan says prior authorization was not obtained. The Plan also says that there is no network 
deficiency for these services and alternate network providers were found. 
 
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 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 GeneSight testing (81479) provided on March 14, 2022, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on July 29, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the lab services. You say that the testing attempts to minimize pain. The Plan 
denied your request. The Plan says utilization of network providers and authorization for certain services is 
required. 
 
 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 did not pre-approve the item/service 
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 lab services provided on July 29, 2022, by an out-of-network (OON) 
provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc-One. 
 
You asked the Plan to pre-approve Synvisc-One. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 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 Synvisc-One. Our reviewer says that 
the documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has pain related to osteoarthritis of the left knee, diagnosis confirmed with imaging studies. 
The enrollee has failed conservative treatment. The documentation does not support that the enrollee has tried 
and failed Euflexxa, Supartz FX, Durolane, or Gelsyn-3. The documentation does not support that Euflexxa, 
Supartz FX, Durolane, or Gelsyn-3 would likely be less effective and/or likely have adverse effects for the 
enrollee. Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc-One.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are 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 your medical problems are stable and there are no complex nursing or rehabilitation 
needs. While the medical record supports a need for physical or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for crown lengthening (D4249) provided on June 8, 2022. 
 
You asked the Plan to pay for crown lengthening. You say that the service was necessary. The Plan denied your 
request. The Plan says the service at issue is not a covered benefit. 
 
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 crown 
lengthening (D4249) provided on June 8, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service September 
16, 2022. 
 
You asked the Plan to pay for procedure code 76641. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service September 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cervical, multiple post collar, occipital/mandibular supports, 
adjustable (L0180) provided July 28, 2022. 
 
You asked the Plan to pay for the orthosis. You say that you have attached the supporting documentation. 
Please reprocess the claim. The Plan denied your request. The Plan says the documentation submitted did not 
sufficiently support the billed supply code. 
 
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 pay for the orthosis. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record does not support that a cervical collar with adjustable supports is medically 
necessary. The record does not indicate the necessity for a collar, or the type of collar needed.  
 
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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pay for cervical, multiple post collar, occipital/mandibular supports, adjustable (L0180) provided July 
28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interspinous spacer placement (22840, 22612). 
 
You asked the Plan to pre-approve the procedure. You say that this service is medically necessary. The Plan 
denied your request. The Plan says this 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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found current evidence-based medical guidelines and peer-reviewed literature do not fully support the 
interspinous fusion device procedure over standard lumbar fusion. There is a lack of large-volume, long-term, 
peer-reviewed outcome studies to support the use of this device for this enrollees medical condition 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an interspinous spacer placement (22840, 22612).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zolpidem. 
 
You asked the Plan to pre-approve Zolpidem. The Plan denied your request. The Plan says outpatient 
prescription drugs are not covered. 
 
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 Zolpidem.  
 
 
 Benefits for Zolpidem 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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FoundationOne Liquid CDx test (0239U) provided on July 6, 2022. 
 
You asked the Plan to pay for the FoundationOne Liquid CDx test. You say that this test was medically 
necessary. The Plan denied your request. The Plan says that the date-of-service should be reported as the date 
the specimen was collected. 
 
The Plan must follow Medicare rules. The rules say that in the case of a molecular pathology test performed by 
a laboratory other than a blood bank or center, or a test designated by CMS as an ADLT, the date of service 
must be the date the test was performed if the criteria in the Medicare Rules section of this letter are met.. 
 
We looked at the file and Medicare rules. In this case the laboratory test performed is considered an ADLT. 
The sample in this case was collected during a hospital outpatient counter. Therefore, the date-of-service was 
correctly reported as the date the test was performed, July 6, 2022. Therefore, we decided that the Plan has to 
pay for the FoundationOne Liquid CDx test (0239U) provided on July 6, 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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 test (81479) provided on February 18, 
2022. 
 
You asked the Plan to pay for the Guardant360 test. You say that the service was medically necessary. The 
Plan denied your request. The Plan says the enrollees claim would be covered under Original Medicare as it is 
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.  
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 the Guardant360 test (81479) provided on February 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services (90834) provided on July 26, 
2022. 
 
You asked the Plan to pay for the psychotherapy services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says a secondary only diagnosis code 
cannot be used as the primary/first-listed diagnosis for any procedure or service. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules say that the ICD-10-CM has a coding 
convention that requires the underlying condition be sequenced first, if applicable, followed by the 
manifestation 
 
We looked at the file and Medicare rules. In this case, this code was billed with a primary/first-listed diagnosis 
code of F01.50 (Vascular dementia without behavioral disturbance). Certain conditions have both an 
underlying etiology and multiple body system manifestations due to the underlying etiology. For such 
conditions, it is required that the underlying condition be sequenced first followed by the manifestation. That 
means the primary/first-listed diagnosis code is incorrect for this code. Based on this information, we decided 
that Medicare rules for coverage of the psychotherapy services have not been met. Therefore, we decided that 
the Plan does not have to pay for the psychotherapy services (90834) provided on July 26, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Atezolizumab. 
 
You asked the Plan to pre-approve Atezolizumab. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested drug is not medically necessary. 
 
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 Atezolizumab. Our reviewer says that 
the documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has a diagnosis of extrapulmonary small cell with high PDL-1 expression. The 
Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested 
drug in the enrollee's clinical situation. Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Atezolizumab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Atezolizumab.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service May 29, 
2022. 
 
You asked the Plan to pay for procedure code 99053. The Plan denied your request. The Plan says procedure 
code 99053 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
99053 billed for date of service May 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74175 billed for services provided on July 
12, 2022. 
 
You asked the Plan to pay for the billed services. You say that the records support this procedure was 
performed. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim. 
 
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. 
 
 
 
 The file shows that codes 74175-26 and 74175-26-76 were billed. We looked at the file and Medicare rules. 
The file shows that procedure code74175-26 was reimbursed by the Plan on September 16, 2022. This claim 
line is an exact duplicate. There is no evidence presented to support that the billed service was provided twice 
on the same date. For code 74175-26-76, the documentation does not show that a repeat procedure by the same 
physician was provided on the date of service at issue. Based on this information, we decided that the Medicare 
rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
code 74175 billed for services provided on July 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical extractions (D7210 x6), alveoloplasty (D7311 x4), 
general anesthesia (D9222, D9223 x7), and a panoramic radiographic image (D0330) provided on September 
21, 2022, by an out-of-network provider. 
 
You asked the Plan to pay for the dental services. You say that the services were necessary, and you want the 
Plan to pay. 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 surgical extractions (D7210 x6), alveoloplasty (D7311 x4), general anesthesia (D9222, D9223 x7), 
and a panoramic radiographic image (D0330) provided on September 21, 2022, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for medical eye exam provided on July 11, 
2022. 
 
You asked the Plan to waive the copayment for medical eye exam. You say that this was routine exam so it 
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 $30 
copayment for Medical eye exam. 
 
You have been asked to pay a $30 copayment for medical eye exam. This item/service falls within the Medical 
eye exam 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 medical eye exam provided 
on July 11, 2022.