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

We decided that the Plan does not have to pay for the extraction (D7210), provided on April 22, 2021.
You asked the Plan to pay for the extraction. You say that the service should be covered. The Plan denied your
request. The Plan says this service is not covered when obtained out-of-network.
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, 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 the
extraction (D7210), provided on April 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for coverage.
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 there are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. 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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the push wheelchair and accessories, for the enrollee. 
 
You asked the Plan to pre-approve the DME. You say that the enrollee must have a wheelchair but was denied 
due to the residence; however, their residence is actually their home. You state the enrollee has been residing in 
a nursing home for thirteen (13) years; therefore, this is their primary residence, and they must have a 
wheelchair to transport and be mobile. The Plan denied your request. The Plan says the requested service is not 
covered by Medicare or the health plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Your records show that you will use the wheelchair in a nursing home (also called a skilled nursing facility or 
SNF). Medicare criteria do not cover the request. The wheelchair must be for use in your home (not a hospital 
or nursing home). Medicare does not cover a wheelchair when you live in a nursing home. Therefore, we 
decided that the Plan does not have to pre-approve the push wheelchair and accessories, for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the custom breast prosthesis, post mastectomy, molded 
to patient model (L8035). 
 
You asked the Plan to pre-approve the breast prosthesis. You say that the medical records provided support the 
necessity of the services. The Plan denied your request. The Plan says the request is not medically necessary 
under Medicare guidelines. 
 
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 breast prosthesis. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the medical necessity for the additional features of a custom fabricated prosthesis 
(L8035) compared to a prefabricated silicone breast prosthesis has not been established, and therefore, if an 
L8035 breast prosthesis is billed, it will be denied as not reasonable and necessary. The review has determined 
that the items/services at issue 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 breast prosthesis have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the custom breast prosthesis, post mastectomy, molded to patient model (L8035).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Pertuzumab, Paclitaxel, Trastuzumab-Anns, Ondansetron, Dexamethasone, Famotidine and Diphenhydramine for the enrollee.
You asked the Plan to pre-approve these drugs. You say that these drugs are medically necessary for the enrollee. The Plan denied your request. The Plan says that the drug/regimen is not being prescribed for a medically-accepted indication.
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 these drugs. Our reviewer says that these drugs are not medically reasonable and necessary. These drugs are not FDA-approved for the enrollee's diagnosis as the tumor is not HER2 positive. The use of these drugs is not supported by one of the major drug compendia or by clinical research that appears in a Centers for Medicare & Medicaid Services approved medical journal. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage
of these drugs. 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 drugs have not been met. Therefore, we decided that the Plan does not have to pre-approve Pertuzumab, Paclitaxel, Trastuzumab-Anns, Ondansetron, Dexamethasone, Famotidine and Diphenhydramine for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-of-network provider.
You asked the Plan to pre-approve the out-of-network services. You say that the services are necessary. The Plan denied your request. The Plan says as medically necessary services are available within the enrollee's network, and there are no extenuating circumstances making it medically necessary to obtain the service out-of-network.
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 physical therapy services to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the hearing aid provided on November 1, 2021. 
 
You asked the Plan to pay for the hearing aid. You say that the item should be covered. The Plan denied your 
request. The Plan says that you received this item through an out-of-network provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan pays for one 
hearing aid every year with a $500 maximum allowance. 
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aid have been met. Specifically, the Plan's EOC does not indicate you must receive 
there supplemental hearing aid benefit through a network provider. Therefore, we decided that the Plan has to 
pay for the hearing aid provided on November 1, 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 MRI, spinal canal and contents, lumbar; without
contrast material (CPT code 72148), for the enrollee.
You asked the Plan to pre-approve the MRI. You say that the service is necessary. The Plan denied your
request. The Plan says the service is not necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 the MRI. Our physician reviewer found
multiple MRIs had been performed over the years including a recent MRI lumbar spine that was performed on
May 19, 2021, showing grossly stable with moderate disc bulges at L2-3 and L3-4 with moderate spinal canal
narrowing without significant neuroforaminal stenosis or nerve root impingement. Repeat MRI lumbar spine
was requested. There are insufficient objective findings from exam to support repeat MRI at this time as there
was no evidence of a red flag diagnosis or significant worsening of the enrollee's chronic condition or plans for
surgery to justify repeat MRI. Therefore, MRI will be considered not medically necessary at this time. 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 MRI have not been met. Therefore, we decided that the Plan does not have
to pre-approve MRI, spinal canal and contents, lumbar; without contrast material (CPT code 72148), for the
enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core build up (D2950) and crown (D2740) for tooth # 30 provided on August 24, 2021.
You asked the Plan to pay for the dental services. You say that the crown on this tooth has come off repeatedly in the past. You say that the dental office had received a fax on June 16, 2020, advising that the treatment would be covered. You also say that your card did not change for 2021 and therefore you expected your coverage to be the same. The Plan denied your request. The Plan says the core build up and crown are not listed as covered services.
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, the core build up and crown are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core build up (D2950) and crown (D2740) for tooth # 30 provided on August 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on July 14, 2021. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like reconsideration because 
this testing was medically necessary. The Plan denied your request. The Plan says the number of tests ordered 
surpasses the number of tests that would be needed. 
 
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 Guardant360 testing. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this enrollee had a liquid next generation sequencing (NGS) on June 21, 2021. There 
is no documentation that tissues were unavailable for sequencing. The National Comprehensive Cancer 
Network guidelines recommend liquid biopsy if there is insufficient tissue for NGS from the tumor. 
 
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 Guardant360 testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the Guardant360 testing provided on July 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aid (V5257), provided on August 4, 2021.
You asked the Plan to pay for the hearing aid. You say that the service should be covered. The Plan denied your request. The Plan says benefits must be obtained through a Plan provider.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only purchased through a Plan provider. We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aid have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aid (V5257), provided on August 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an arm cast application with facility 
charges performed on September 14, 2021. 
 
You asked the Plan to waive the copayment for the cast application and facility charges. You say that you were 
not seen at the hospital and you feel that the charges are in error. The Plan denied your request. The Plan says 
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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 
copayment for surgery or other services provided at an outpatient hospital facility, including other facility 
charges and physician or surgical charges. 
 Service Copayment per EOC Actual Charges 
Cast Application $350 $279.85 
Facility Charge $350 $137.78 
Total:  $417.63 
 
You have been asked to pay $417.63 for the cast application and facility charges. The cast application and 
facility charges fall within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities 
and Ambulatory Surgical Centers 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 
an arm cast application with facility charges performed on September 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a renal biopsy provided on December 7, 
2020. 
 
You asked the Plan to waive the copayment for a renal biopsy. You say that you should not owe a copayment 
for diagnostic tests and the $150 charge is unwarranted. The Plan denied your request. The Plan says the claims 
were processed correctly and you are being charged the correct amount. 
 
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 outpatient surgery, including services provided at hospital outpatient facilities. 
 
You received a renal biopsy on December 7, 2020, at an outpatient hospital facility. A renal biopsy is 
considered an outpatient surgical procedure. Therefore, you are responsible to pay the $150 copayment.   
 
 
 You have been asked to pay a $150 copayment for a renal biopsy. A renal biopsy falls within the outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 a renal biopsy provided on December 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral - complete series of radiographic images (D0210) provided November 1, 2021.
You asked the Plan to pay for the complete series of intraoral x-rays. You say that you haven't had x-rays in 16 years and your dentist felt these were necessary. The Plan denied your request. The Plan says this service is not covered under your benefits.
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, 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 the intraoral - complete series of radiographic images (D0210) provided November 1, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiopulmonary resuscitation (92950) and emergency 
department (ED) visit (99285) provided on June 9, 2021. 
 
  You asked the Plan to pay for the cardiopulmonary resuscitation and ED visit. The Plan denied your request. 
The Plan says the enrollee's hospice care started May 5, 2021, through June 5, 2021. The Plan also says that 
Original Medicare covers services for an enrollee until the first of the following month after the enrollee 
disenrolls from Hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on June 5, 2021. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for the cardiopulmonary 
resuscitation (92950) and emergency department (ED) visit (99285) provided on June 9, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood smear, peripheral, interpretation by physician with 
written report (CPT code 85060) provided on September 20, 2021. 
 You asked the Plan to pay for the service. You say that you submitted supporting documentation for 
reconsideration of denied code. The Plan denied your request. The Plan says CPT code 85060 has a 
Professional Component (PC)/Technical Component (PC/TC) indicator of 8 per the Physician Fee Schedule 
Search. The Plan states CPT code 85060 may not be paid if furnished to hospital outpatients or non-hospital 
patients. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the service have not been met. The denied CPT code 85060 may 
not be paid if furnished to hospital outpatients or non-hospital patients. Review of the members claim shows 
the provider billed in a place of service of 22 Outpatient Hospital. If the provider determines that a billing error 
occurred during the initial submission of the denied claim, the plan will accept a submission of a corrected 
claim to consider services for payment. Therefore, we decided that the Plan does not have to pay for the blood 
smear, peripheral, interpretation by physician with written report (CPT code 85060) provided on September 20, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
October 15, 2021. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that you were not satisfied with the 
services you received at the previous provider. You also say that you went to the new provider and because you 
were a new patient, they had to do their own examination. The Plan denied your request. The Plan says this 
service exceeds the frequency limitation in your benefit plan. 
 
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, comprehensive oral evaluation 
(D0150) is limited to one procedure every three plan years. The record shows that you received a 
comprehensive oral evaluation (D0150) on September 3, 2020 and your comprehensive oral evaluation 
(D0150) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the 
comprehensive oral evaluation (D0150) provided on October 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit (99283) provided November 7, 2019.
You asked the Plan to pay for the emergency visit. You say that please review the attached medical record and reprocess the claim for additional payment. The Plan denied your request. The Plan says this claim was received past the timely filing limitation.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the emergency visit was not filed until December 9, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the emergency department visit (99283) provided November 7, 2019.