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

 
We decided that the Plan does not have to pay for the genetic testing provided on April 15, 2022. 
 
You asked the Plan to pay for the testing services. You say that the testing clarifies disease risk. The Plan 
denied your request. The Plan says coverage of the gene panel has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
 We find that the testing at issue is not supported in the medical record. The records do not show that the 
enrollee has a personal history or signs and symptoms of breast, ovarian, pancreatic, or prostate cancer. Based 
on this information, we decided that Medicare rules for coverage of the testing services have not been met. 
Therefore, we decided that the Plan does not have to pay for the genetic testing provided on April 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on February 23, 2022. 
 You asked the Plan to pay for the services provided. You say that the test identifies possible treatment options. 
The Plan denied your request. The Plan says the unique test identifier is missing. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
The claim information does not include the appropriate DEX Z-Code. Based on this information, we decided 
that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the 
Plan does not have to pay for the lab testing services provided on February 23, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the dental implants and crowns provided July 23, 
2021 to August 16, 2021. 
 
You asked the Plan to reimburse you for the dental services. You say that you are requesting immediate 
reimbursement of the amount you paid of $4,000 and for the dental services, plus the cost of $4,000 for 
hospitalization and treatment due to malpractice by the provider. The Plan denied your request. The Plan says 
these services are not covered under the Plan benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for 
the dental implants and crowns provided July 23, 2021 to August 16, 2021.  
 Your complaint about malpractice is not a valid appeal for medical coverage. This part of your complaint is a 
grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types 
of complaints.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (87798, 87641, 88305, 88312) provided 
on June 3, 2021. 
 
You asked the Plan to pay for laboratory services. You say that you have submitted documentation for 
reconsideration of the denied claim. The Plan denied your request. The Plan says the provider signing off on 
the pathology report, is ineligible to bill Medicare. Medical records from the ordering provider were not 
submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. The records show that the provider who signed for the lab results is 
not eligible with Medicare. The records also show that the ordering provider did not submit medical records or 
laboratory results. Based on this information, we decided that Medicare rules for coverage of laboratory 
services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services 
(87798, 87641, 88305, 88312) provided on June 3, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH admission is medically 
necessary. The Plan denied your request. The Plan says LTACH admission is not medically necessary because 
the patient can adequately receive ongoing acute level care in the current location. In addition to oxygen 
weaning, the member requires telemetry, tube feedings, respiratory therapy, tracheostomy and feeding tube 
care, frequent labs and doctor visits, and therapy, all of which can be safely done in the current acute care 
setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the patient is a 65 year old female who was admitted to the acute care hospital with 
pulseless electrical activity following fentanyl and cocaine ingestion requiring oxygen, tube feeds, antibiotics, 
mechanical ventilation support, respiratory therapy, and trach and feeding tube placement. Recent notes 
describe the patient participating in therapy and tolerating trach mask having completed antibiotics. The patient appears to be more stable and improving and should only require short-term additional acute care hospital 
services that can be safely administered at the current facility until stable and appropriate for a lower level of 
care. The patient does not require services at the LTACH that are not already available at the current 
facility. There are no services at the LTACH that the patient requires that are not already available and covered 
at the current facility. Transfer to the LTACH is not medically necessary as it would not be clinically 
advantageous at this time. Completion of treatment at the current facility is 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 29, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. The claim in this case was billed with the laboratory POS code. The 
records do not support that the sample was taken in a laboratory setting Based on this information, we decided 
that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan 
does not have to pay for lab services provided on July 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Level IV, surgical pathology, gross and microscopic 
examination (88305) special stain including interpretation and report (88312) provided March 24, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim was denied in error. Please review 
the attached supporting documents and reprocess the claim for payment. The Plan denied your request. The 
Plan says services received from ineligible provider. 
 
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 Level IV, surgical pathology, gross and 
microscopic examination (88305) special stain including interpretation and report (88312) provided March 24, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) 
supplies rendered from March 2, 2022, to April 2, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no valid physician order. 
 
The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating 
physician before dispensing any durable medical equipment (DME) item to a beneficiary. 
 
We looked at the file and Medicare rules. There is no valid physician order for the DME. Based on this 
information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we 
decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) supplies 
rendered from March 2, 2022, to April 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shingles and Tdap vaccines you received on March 30, 
2022. 
 
You asked the Plan to pay for the shingles and Tdap vaccines. You say that your primary care provider gave 
you these vaccines without asking you.  You said that you had no idea that some vaccines must be received at a 
pharmacy.  You said that the doctor's office should check the patient's insurance coverage before administering 
vaccines. The Plan denied your request. The Plan says these vaccines are not covered under your medical 
benefits. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles and 
Tdap vaccines. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the shingles and 
Tdap vaccines. Therefore, we decided that the Plan does not have to pay for the shingles and Tdap vaccines 
you received on March 30, 2022.  
 
Benefits for the shingles and Tdap vaccines 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: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve lower extremity revascularization of the iliac arteries for the 
enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that that medical need has not been met for both iliac arteries because 
records do not show imaging studies that confirm the site of blockage to be more than 50 percent. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 these services. Our reviewer says that 
the requested services are considered medically reasonable and necessary in this case. The patient is described 
as having severe claudication and rest pain consistent with limb threatening ischemia. There is documentation 
by the provider whose interpretation of the Computed tomography angiography (CTA) demonstrates severe 
iliac stenosis. It would not be reasonable for the provider to proceed with angiography without the assurance 
that if a significant lesion in the iliac artery is confirmed by angiography, its treatment would be covered. 
Review of the medical record suggests that there is enough evidence that medically necessary iliac artery 
treatment may be required. Furthermore, the providers description of severe stenosis in the iliac artery satisfies 
the coverage criterion for documentation of a 50% or greater lesion. Our physician reviewer found that the 
enrollee's condition meets criteria for coverage of these 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 these services have been met. Therefore, we decided that the Plan has to pre-
approve lower extremity revascularization of the iliac arteries for the enrollee.  
 
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 Injection, Drainage, or Aspiration Procedures on the Spine 
and Spinal Cord provided on March 10, 2022. 
 
You asked the Plan to pay for Injection, Drainage, or Aspiration Procedures on the Spine and Spinal Cord. The 
Plan denied your request. 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 Plan says that the Plan has 
also determined that these services are 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 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 Injection, Drainage, or Aspiration Procedures on the Spine and 
Spinal Cord provided on March 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for office visit on March 25, 2022. 
 
You asked the Plan to waive the cost sharing for office visit. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost sharing you are being charged is correct. 
 
 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for services obtained from a primary care provider or under certain circumstances, treatment by a 
nurse practitioner or physicians assistant or other non-physician health care professionals in a primary care 
providers office (as permitted under Medicare rules). Covered services include medically-necessary medical or 
surgical services furnished in a physicians office. The provider billed the plan in the amount of $500.00 and 
the allowed amount is $169.57. Since the deductible was not met, the remaining deductible of $24.14 was 
applied. This left a remaining allowed amount of $145.43 ($169.47 - $24.14). The 20% coinsurance was 
calculated from this new allowable amount, and a coinsurance of $29.09 was applied ($145.43 x 20%). $24.14 
+ $29.09 = $53.23. Therefore, results in the total cost sharing amount of $53.23. 
 
You have been asked to pay $53.23 cost share for office visit. Office visits fall within the Physician/practitioner 
services, including doctor's office visits 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 cost sharing 
for office visit on March 25, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total hip replacement. 
 
You asked the Plan to pre-approve a total hip replacement. You say that the records provided support the need 
for a total hip replacement. The Plan denied your request. The Plan says the requested surgery is not medically 
necessary. 
 The Plan follows Medicare rules. Medicare rules say that total hip replacement is covered for certain medical 
indications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a total hip replacement. Our reviewer 
says that the criteria for coverage have not been met. Our physician reviewer found the enrollee is being treated 
for unilateral primary osteoarthritis of the right hip. She presented with bilateral hip pain. The exam of the 
bilateral hips revealed positive tenderness of the anterior hip. There is a decreased range of motion. However, 
detailed documentation is not evident regarding trial and failure of recent, reasonable, and comprehensive less 
invasive conservative care measures. 
 
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 total hip replacement have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a total hip replacement.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a presumptive drug test represented by code 80307 and billed 
for date of service May 2, 2022. 
 
You asked the Plan to pay for code 80307. You say that the medical records provided support the services in 
dispute. The Plan denied your request. The Plan says a presumptive urine drug test was already paid out for the 
enrollee on this date of service and the claim in dispute is redundant. 
 
The Plan must follow Medicare rules. Medicare rules say that a maximum of one presumptive urine drug test 
may be submitted and paid per patient, per date of service. 
 
We looked at the file and Medicare rules. The records show that the Plan already paid for a presumptive urine 
drug test performed on May 2, 2022, and billed under claim number 820221260043811. Based on this 
information, we decided that Medicare rules for coverage of code 80307 have not been met. Therefore, we 
decided that the Plan does not have to pay for a presumptive drug test represented by code 80307 and billed for 
date of service May 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF testing provided on October 20, 2021.  
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that NGS is covered when the coverage criteria are met in 
the applicable NCD. 
 
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 testing. Our reviewer says that the 
requested Tempus xF testing is not medically reasonable and necessary. Our physician reviewer found that the 
request did not meet Medicare rules as the testing performed was not FDA approved. The requested Tempus xF 
testing was not medically reasonable or necessary according to the coverage criteria in the NCD. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the Tempus xF testing provided on October 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stance flexion feature (L5845) and an outer surface 
cover (L5964) for a prosthetic leg. 
 
You asked the Plan to pre-approve a stance flexion feature and an outer surface cover. You say that the 
requested items are a medical necessity for you. The Plan denied your request. The Plan says medical-necessity 
rules for the requested items have not been met. 
 
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 a stance flexion feature and an outer 
surface cover. Our reviewer says that the requested items are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that the outer surface cover is not medically necessary as 
you do not need the special environmental coverage. The stance flexion feature is not a medically necessary 
addition to the knee system. 
 
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 stance flexion feature and an outer surface cover have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a stance flexion feature (L5845) and an outer 
surface cover (L5964) for a prosthetic leg.