Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Partially Favorable

We decided that the Plan has to pay for the testing described by code 88189. We decided that the Plan does not
have to pay for the remaining billed codes.
You asked the Plan to pay for the testing described by code 88189. You say that this was billed correctly and
should be paid. The Plan says that the records do not include results to support all the codes billed.
We decided that the Plan has to pay for the testing described by code 88189.
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly.
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 described by code 88189. Our
reviewer says that the laboratory results only support that flow cytometry on 16 or more markers was
performed, as described by code 88189. The remaining codes are not supported as being performed based on
the records provided.
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 described by code 88189 have been met. Therefore, we decided that
the Plan has to pay for the testing described by code 88189.
We also decided that the Plan does not have to pay for the remaining billed codes.
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly.
As noted in the above section, our physician reviewer says that the remaining codes are not supported. 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 remaining billed codes have not been met. Therefore, we decided that the
Plan does not have to pay for the remaining billed codes.
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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90834) provided on April 9, 2021.
You asked the Plan to pay for psychotherapy services. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. Medicare rules say that the CP will attempt to consult with the enrollee's attending or primary care physician.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of psychotherapy services have not been met. Specifically, the provided records do not document an
attempt to consult with, nor a referral from, the enrollee's attending or primary care physician. Therefore, we
decided that the Plan does not have to pay for psychotherapy services (90834) provided on April 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a wig purchased by the enrollee on June 24, 2021. 
 
You asked the Plan to pay for a wig. You say that a wig was medically necessary for the enrollee for hair loss 
due to cancer treatment. The Plan denied your request. The Plan says wigs are not covered by Medicare. 
 
Medicare may pay for items which either meet the definition of durable medical equipment or a prosthesis.  
The Plan follows these same rules. In this case, a wig does not meet the definition of the above benefit 
categories. It is not considered durable medical equipment because it does not directly treat a physical medical 
condition. It does not meet the Medicare definition of a prosthetic because it does not replace an internal body 
organ or attached tissue. The Plan does not offer a supplemental benefit which would provide coverage for a 
wig. Therefore, we decided the Plan does not have to pay for a wig purchased by the enrollee on June 24, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the FoundationOne CDx testing rendered on April 22, 2021.
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 the testing was not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that molecular pathology is covered when specific criteria are met. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the testing was not medically necessary. Our physician reviewer found the documentation includes a test requisition form, a surgical pathology report, and the results of the testing. There are no additional clinical records. The documentation is insufficient to demonstrate that the comprehensive genomic sequence analysis testing in this case was medically reasonable and necessary for the enrollee in this case. 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 not been met. Therefore, we decided that the Plan does not have to pay for the FoundationOne CDx testing rendered on April 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on June 18, 2020.
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 the services were not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on June 18, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services provided on October 7, 2020.
You asked the Plan to pay for outpatient hospital services. You say that The Plan denied your request. The
Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan must 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 outpatient hospital services provided on October 7, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 25, 2020. 
 
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 the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on September 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a shoulder-arm orthosis (L3960) provided on September 17, 
2020. 
 
You asked the Plan to pay for a shoulder-arm orthosis. You say that the item at issue was a medical necessity 
for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The provided medical records do not discuss the item at issue. The record shows that the Plan 
made several attempts to obtain the necessary documentation without success. Therefore, we decided that the 
Plan does not have to pay for a shoulder-arm orthosis (L3960) provided on September 17, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care (99233) provided from 
December 10, 2020, to December 11, 2020. 
 
You asked the Plan to pay for the evaluation and management services. You say that the enrollee was not 
enrolled in hospice on the dates of service in this case. The Plan denied your request. The Plan says fee-for-
service Medicare covers attending physician services and all care unrelated to the terminal illness until the first 
day of the month following the month in which hospice was revoked or discharged. 
 
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 December 7, 2020. 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 subsequent 
hospital care (99233) provided from December 10, 2020, to December 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on 
February 15, 2021 by a Medicare opt out provider. 
 
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that this was for your six-
month checkup which the Plan had paid in the past with no questions asked. The Plan denied your request. The 
Plan says you received these services from a provider who chose not to receive Medicare funds. The Plan also 
says that you made no attempts to contact the Plan prior to this date of service. 
 
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 
covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the 
Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on February 15, 2021 by a 
Medicare opt out provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the case presentation, detailed and extensive treatment 
planning (D9450) provided on June 22, 2021. 
 
You asked the Plan to pay for the dental service. You say that you called ahead before getting the full mouth x-
rays. You say that you were advised the copayment would be $17. You also say that the x-rays were denied. 
The Plan denied your request. The Plan says the case presentation, detailed and extensive treatment planning, is 
not listed as a covered service. 
 
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 case presentation, detailed and 
extensive treatment planning, is not among those covered under this benefit. Therefore, we decided that the 
Plan does not have to pay for the case presentation, detailed and extensive treatment planning (D9450) 
provided on June 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve destruction of upper or middle spinal facet joint nerves using imaging guidance (64633) and destruction of upper or middle spinal facet joint nerves with imaging guidance (64634).
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 your records show you have not had at least 2 diagnostic MBBs at the requested level for this radiofrequency ablation.
The Plan must follow Medicare rules. Medicare rules say that RFA can be covered if the LCD criteria has been met. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Medicare rules requires two sets of diagnostic medial branch blocks that produce greater than 80% sustained relief of primary (index) pain. Only one set is documented. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for 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 not been met. Therefore, we decided that the Plan does not have to pre-approve destruction of upper or middle spinal facet joint nerves using imaging guidance (64633) and destruction of upper or middle spinal facet joint nerves with imaging guidance (64634).
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 the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.
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 you are receiving appropriate care at the present acute care facility. There are no services available at the LTACH that you require 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 long term acute care hospital (LTACH) services
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for a core buildup, including any pins 
when required (D2950) provided on May 13, 2021. 
 
You asked the Plan to pay an additional amount for a core buildup. You say that at this time this is quite a 
hardship for you to even have the original dental cost, much less an additional amount owed. 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 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 an additional 
amount for a core buildup, including any pins when required (D2950) provided on May 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scalings and root planings (D4341) of the 
lower left, lower right, upper left, and upper right quadrants. 
 
You asked the Plan to pre-approve the scalings and planings. The Plan denied your request. The Plan says there 
is insufficient evidence to indicate that deep cleaning of tooth roots is necessary. 
 
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. The Plan covers the scalings 
and planings when the services are medically necessary and reasonable.  
 
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 scalings and planings. Our reviewer 
says that these services are not medically reasonable and necessary for the enrollee. Our physician reviewer 
found there is no notable loss of bone, and the root surfaces of all teeth seen on x-ray are still covered by the 
alveolar bone making planing of the root surfaces impossible. Our reviewer also found that there may be 
inflammation of the gingiva present (though no charting was included), but without loss of attachment there is 
no basis for periodontal treatment under code D4341. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the scalings and planings have not been met. Therefore, we decided that the 
Plan does not have to pre-approve periodontal scalings and root planings (D4341) of the lower left, lower right, 
upper left, and upper right quadrants.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prosthesis with advanced knee and foot (CPT code(s) 
L5986, L5981 and L5845). 
 
You asked the Plan to pre-approve the prosthetic. You say that the items are necessary. The Plan denied your 
request. The Plan says the records they have do not show why the requested advanced foot and knee are 
needed. The Plan states other knees and feet are available that can meet the enrollee's needs. 
 
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 prosthetic. Our physician reviewer 
found physical therapy has recommended you advance to knee and feet prosthesis with your existing sockets in 
order to be more independent and have normal locomotion. A request was made for a prosthesis with advanced 
knee and foot. A review of the provided documentation did not clearly reveal the reason "advanced" knee and 
foot prosthesis was requested instead of another knee and foot prosthesis. There was no report of failure of a 
regular prosthesis or why other devices would be inappropriate for you. Therefore, this request for prosthesis 
with advanced knee and foot does not meet criteria for Medicare coverage. 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 prosthetic have not been met. Therefore, we decided that the Plan does not have to pre-approve a prosthesis 
with advanced knee and foot (CPT code(s) L5986, L5981 and L5845).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on 
October 13, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must 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 services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the services provided by an out-of-network provider on October 
13, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic consultation (D9310) and intraoral x-ray 
(D0220) provided on July 7, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were referred to this provider and these 
services were necessary. The Plan denied your request. The Plan says they have agreed to cover the root canal 
as an in-network service; however, the diagnostic consultation is not covered regardless of the participation 
status of the provider, and you have exhausted your benefit limit for intraoral x-rays. 
 
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. The Plan does not cover 
services that are not listed in the dental benefits chart. The Plan can cover up to one intraoral x-ray per calendar 
year. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested diagnostic consultation is 
not among those covered under this benefit. The Plan also provided documentation that you received a previous 
intraoral x-ray in May of 2021, which was covered at that time. This means that the intraoral x-ray received on 
July 7, 2021, exceeded the frequency limitation of your dental benefit. Therefore, we decided that the Plan does 
not have to pay for the diagnostic consultation (D9310) and intraoral x-ray (D0220) provided on July 7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on March 29, 2021. 
 
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 the testing is not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on March 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ilumya (J3245).
You asked the Plan to pre-approve Ilumya. The Plan denied your request. The Plan says this request does not meet the Plan's Part B step therapy criteria for Ilumya.
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Ilumya have not been met. No medical records were provided to us to base a decision on. Therefore, we decided that the Plan does not have to pre-approve Ilumya (J3245).