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

 
We decided that the Plan does not have to pay for a limited re-evaluation (D0170) provided by a participating 
provider on September 8, 2021, to September 29, 2021. 
 
You asked the Plan to pay for a limited re-evaluation. You say that you do not agree with these charges. The 
Plan denied your request. The Plan says the rendered service has been correctly denied. 
 
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 a limited 
re-evaluation (D0170) provided by a participating provider on September 8, 2021, to September 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (83789) provided on August 5, 2021. 
 
You asked the Plan to pay for code 83789. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 We looked at the file and the rules. We find that CPT code 83789 was billed for specimen validity testing. 
Validity testing on urine specimens used for drug testing shall not be separately billed. Therefore, we decided 
that the Plan does not have to pay for the laboratory service (83789) provided on August 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an opt-out provider on May 7, 
2021, to November 4, 2021. 
 
You asked the Plan to pay for dental services. You say that you were misled by the Plan. The Plan denied your 
request. The Plan says this provider is on the opt-out list. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program until September 22, 2023. Therefore, we decided that the Plan does not 
have to pay for dental services provided by an opt-out provider on May 7, 2021, to November 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary services provided on December 1, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for domiciliary services. You say that that it isn't your responsibility to obtain prior 
authorization. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for domiciliary services provided on December 1, 
2021 by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing home long-term care hospice services provided from 
January 10, 2022, to January 31, 2022. 
 
You asked the Plan to pay for nursing home long-term care hospice services. You say that you would like this 
service covered. The Plan denied your request. The Plan says original Medicare is responsible for payment. 
 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 nursing home long-term care hospice services provided from 
January 10, 2022, to January 31, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for paramedic intercept services provided on January 11, 2022. 
 
You asked the Plan to pay for paramedic intercept services. The Plan denied your request. The Plan says the 
paramedic intercept services provided were not rendered in a rural area. 
 
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. 
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as defined above. It is noted that the only State in which these criteria are met is New York. 
 
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural 
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for paramedic 
intercept services provided on January 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional Group 2 power wheelchair. 
 
You asked the Plan to pre-approve an additional Group 2 power wheelchair. You say that you will not be able 
to function without this wheelchair. The Plan denied your request. The Plan says that you received a Group 2 
power wheelchair in May 2022. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a Group 2 power wheelchair. A Group 2 power wheelchair serves the same 
purpose as an additional Group 2 power wheelchair. Therefore, we decided that the Plan does not have to pre-
approve an additional Group 2 power wheelchair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on January 3, 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 procedure code G0483 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code G0483 is definitive drug testing, 22 or more drug classes. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the records show that 19 
drug classes were tested. 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 drug testing 
rendered on January 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ConfirmMDx testing provided on January 14, 2022. 
 
You asked the Plan to pay for the ConfirmMDx testing. You say that the provided ConfirmMDx testing 
provided on January 14, 2022, was medically necessary. The Plan denied your request. The Plan says the 
enrollee did not meet criteria for the provided ConfirmMDx testing. 
 
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 ConfirmMDx testing. Our reviewer says 
that the enrollee did not meet criteria for the provided ConfirmMDx testing. Our physician reviewer found 
previous biopsy histology should not show a prior diagnosis of prostate cancer or cellular atypia suspicious for 
cancer. The records show that the biopsy on January 14, 2022, shows atypia. 
 
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 ConfirmMDx testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the ConfirmMDx testing provided on January 14, 2022.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for subsequent nursing facility care (99308) provided on March 11, 2021. 
 
You asked the Plan to pay for subsequent nursing care. You say that this service is supported in the record and 
should be paid. The Plan denied your request. The Plan says that this is a duplicate of a previous claim which 
has already been processed, and this service is only payable once per day to the same provider. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided any claim documents which show that 
this claim has already been submitted and paid by the Plan. The only page of claim information provided 
matches the claim ID for which the Plan states this service has already been paid; however, the documentation 
does not show that the claim was paid. In addition, the initial claim forms as they were submitted to the Plan 
were not provided. We cannot verify that the Plan has already paid for 99308 to the same provider on the date 
in question or that the requested service is a duplicate. Therefore, we decided that the Plan has to pay for 
subsequent nursing facility care (99308) provided on March 11, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 15, 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 services were not billed correctly. 
 
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 August 15, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve computed tomography, of the head or brain; without contrast 
material. 
 
You asked the Plan to pre-approve this service. You say that computed tomography of the head or brain is 
medically necessary for the enrollee. The Plan denied your request. The Plan says that a computed tomography 
scan of the head or brain is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 this service. Our reviewer says that 
computed tomography of the head or brain is medically necessary. Our physician reviewer found that the 
patient has a subcutaneous mass in the vicinity of his shunt. Given the location it may be the valve from the 
shunt although it could be a benign Pilar cyst. It is in very close proximity to his hydrocephalus shunt 
catheter. Therefore, the computed tomography scan is medically reasonable and 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 this service have been met. Therefore, we decided that the Plan has to pre-
approve computed tomography, of the head or brain; without contrast material.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eye refraction services received on January 18, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Medicare does not cover routine eye exams (eye refractions) for eyeglasses/contacts. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The services you asked the Plan to pay for are considered refraction. Therefore, we decided that the Plan does 
not have to pay for eye refraction services received on January 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the MRA (70547) provided on February 21, 2021. 
  You asked the Plan to pay for the MRA (70547). You say that procedure code 70547 and 70540 were 
separately performed, medically necessary procedures and billed with appropriate modifiers. You say that the 
reports clearly indicate the procedures were separate and the claim should be reprocessed for payment. The 
Plan denied your request. The Plan says an appropriate modifier was not billed with this code edit. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70547 
is a column II code to column I code 70540. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the MRA (70547) provided on February 21, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee lives alone, had a total knee 
replacement and will be a fall risk at home. The Plan denied your request. The Plan says the enrollee does not 
require daily skilled nursing services.  
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our physician reviewer 
found the enrollee does not qualify for SNF coverage. The enrollee does not have daily skilled nursing needs 
that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does 
not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. The enrollee was at a modified independent to supervision level for functional mobility 
including gait to 225 feet with a rolling walker.  The enrollee required varying assist with activities of daily 
living. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a 
skilled nursing facility (SNF) setting.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3. 
 
You asked the Plan to pre-approve Gelsyn-3. You say that the requested Gelsyn-3 is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail Orthovisc OR Supartz FX. 
 
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 Gelsyn-3. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found based on the documentation 
provided, the enrollee is noted to have bilateral knee osteoarthritis.  A request has been made for Gelsyn, a 
hyaluronic acid injection, to treat the osteoarthritis.  The health plan requires that other forms of hyaluronic 
acid be used.  There is no evidence that the enrollee is allergic to or intolerant of these other forms of 
medication.  There is no evidence that the enrollee has tried and not responded to these other forms of 
medication.  There is no documentation as to why these other forms of medication would not be expected to be 
safe and effective for the enrollee.  Therefore, the requested Gelsyn is not shown to be currently medically 
necessary and reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gelsyn-3.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided to the enrollee on January 25, 2022. 
 
You asked the Plan to pay for the services. You say that all of the codes were billed correctly. The Plan denied 
your request. The Plan says the service is not allowed as it was submitted with missing or invalid information. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99214 is "Office or other outpatient visit for the 
evaluation and management of an established patient, which requires a medically appropriate history and/or 
examination and moderate level of medical decision making. When using time for code selection, 30-39 
minutes of total time is spent on the date of the encounter." 
 
We find that CPT code 99214 is not supported in the medical record. Specifically, this code is not recognized 
when submitted on an outpatient claim. Based on this information, we decided that Medicare rules for coverage 
of the services have not been met. Therefore, we decided that the Plan does not have to pay for an office visit 
provided to the enrollee on January 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 1 power wheelchair. 
 
You asked the Plan to pre-approve a group 1 power wheelchair. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says you do not meet criteria for the requested 
item. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file does not support that your home provides adequate access between rooms, maneuvering space, and 
surfaces for the operation of the power operative vehicle. This means that Medicare rules for coverage of a 
PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 1 power 
wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adjunctive pre-diagnostic test (D0431), four gingival 
irrigations (D4921 x4), and drugs or medicaments dispensed in the office for home use (D9630) provided on 
January 6, 2022, and January 10, 2022. 
 
You asked the Plan to pay for the adjunctive pre-diagnostic test, gingival irrigations, and drugs or 
medicaments. You say that prior to receiving these services, you contacted the Plan and were advised it was 
accepted and not an uncommon service. The Plan denied your request. The Plan says these services are not 
covered expenses under your dental plan. The Plan also says that when you contacted the Plan on January 4, 
2022, no inaccurate information was provided. 
 
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 the 
adjunctive pre-diagnostic test (D0431), four gingival irrigations (D4921 x4), and drugs or medicaments 
dispensed in the office for home use (D9630) provided on January 6, 2022, and January 10, 2022.