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

 
We decided that the Plan does not have to pay for the FoundationOne Heme (F1Heme) panel provided on 
October 31, 2021, billed with code 81455. 
 
You asked the Plan to pay for the F1Heme panel. You say that this should be covered due to medical necessity. 
The Plan denied your request. The Plan says this is not a covered test. 
 
The Plan must follow Medicare rules. Medicare rules say that there is sufficient evidence to support the 
medical necessity of Genomic Sequential Analyses panels for patients with AML, MPN, and MDS for a 
limited number of individual biomarkers. Panels which test the covered biomarkers and are described by code 
81450 may be covered by Medicare.   
 
We looked at the file and Medicare rules. Review of the information in the file shows that this panel includes 
analysis of over 50 genes. The billed code 81455 is defined as targeted genomic sequencing with analysis for 
51 or more genes. Although some of these genes may be considered medically necessary based on the rules, the 
entire panel exceeds what is covered under these provisions. Therefore, we decided that the Plan does not have 
to pay for the FoundationOne Heme (F1Heme) panel provided on October 31, 2021, billed with code 81455.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interim partial denture (D5820), provided by a 
participating provider. 
 
You asked the Plan to pre-approve an interim partial denture. You say that you would like the Plan to pay for 
this. The Plan denied your request. The Plan says the requested dental benefit is not covered. 
 
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 pre-approve an 
interim partial denture (D5820), provided by a participating provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs received on January 26, 2022. 
 
You asked the Plan to pay for the drugs. You say that this should be paid for. The Plan denied your request. 
The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs received 
on January 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 2, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration stating services 
should not require authorization because provider is PCP. The Plan denied your request. The Plan says This 
provider is not a network provider with the Plan. We have 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 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 an office visit provided on December 2, 2021 by 
an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an iron infusion provided on  
January 27, 2022. 
 
You asked the Plan to waive the coinsurance for an iron infusion. You say that this service has cost you more 
under the Plan than under Medicare Parts A and B. The Plan denied your request. The Plan says the 
coinsurance applied was 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 in-network Medicare Part B covered drugs. The allowed amount of the claim is $6,579.27, 
resulting in a coinsurance amount of $1,315.85 ($6,579.27 x 20%). 
 
You have been asked to pay $1,315.85 for an iron infusion. An iron infusion falls within the Medicare Part B 
Prescription Drugs 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 coinsurance for an iron infusion 
provided on January 27, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a breast ultrasound provided on November 
30, 2021. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you have had recalls before and 
never had a copayment. 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 $35 
copayment for each X-ray or ultrasound.  
 
The file shows that you had a breast ultrasound and a diagnostic mammogram performed. There is no evidence 
in the file that you were charged for the mammogram. Therefore, you have only been asked to pay a $35 copayment for the ultrasound. The ultrasound falls within the Outpatient Diagnostic Tests and Therapeutic 
Services and Supplies 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 breast 
ultrasound provided on November 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a Dexcom G6 CGM. You say that this is medically necessary. The Plan 
denied your request. The Plan says the requirements for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Dexcom G6 CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Dexcom G6 continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), and a crown (D2740) 
provided by an out-of-network provider on January 4, 2022. 
 
You asked the Plan to pay for a limited oral evaluation (D0140), and a crown (D2740). You say that you are an 
army veteran on total disability. You say that you would like the Plan to pay for this dental work. The Plan 
denied your request. The Plan says this claim has been processed correctly. 
 
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 
oral evaluation (D0140), and a crown (D2740) provided by an out-of-network provider on January 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ophthalmology specialist office visit 
provided on November 15, 2021. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that the provider over charged 
for the visit. You also say that you were not happy with the provider's services. 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 $35 
copayment for an in-network specialist office visit.  
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$35 copayment for a specialist office visit. A specialist office visit falls within the Physician/Practitioner Services, Including Doctors 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 copayment 
for an ophthalmology specialist office visit provided on November 15, 2021.  
 
Your complaint about the providers services 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 the FoundationOne Heme (F1Heme) panel provided on 
September 29, 2021, billed with code 81455. 
 
You asked the Plan to pay for the F1Heme panel. You say that this is medically necessary testing. The Plan 
denied your request. The Plan says the provider listed as ordering this testing was contacted and indicated no 
such testing was ordered by them. 
 
The Plan must follow Medicare rules. Medicare rules say that there is sufficient evidence to support the 
medical necessity of Genomic Sequential Analyses panels for patients with AML, MPN, and MDS for a 
limited number of individual biomarkers. Panels which test the covered biomarkers and are described by code 81450 may be covered by Medicare.  
 
We looked at the file and Medicare rules. Review of the information in the file shows that this panel includes 
analysis of over 50 genes. The billed code 81455 is defined as targeted genomic sequencing with analysis for 
51 or more genes. Although some of these genes may be considered medically necessary based on the rules, the 
entire panel exceeds what is covered under these provisions. Therefore, we decided that the Plan does not have 
to pay for the FoundationOne Heme (F1Heme) panel provided on September 29, 2021, billed with code 81455.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services provided on November 1, 2021, November 29, 2021, December 1, 2021, December 6, 2021, and December 13, 2021, by an OON provider.

You asked the Plan to pay for the physical therapy services. You say that a referral was submitted. The Plan denied your request. The Plan says the rendering and referring providers are both OON providers and there was no approved authorization. Also, the service rendered was not urgent or emergent.
 
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 the physical therapy services provided on November 1, 2021, November 29, 2021, December 1, 2021, December 6, 2021, and December 13, 2021, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an over bed table (E0274). 
 
You asked the Plan to pre-approve the table. You say that this table is medically necessary. The Plan denied 
your request. The Plan says the requested item is non-covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an over bed table (E0274).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a breast ultrasound provided on February 
17, 2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you have never had to pay for 
previous ultrasounds. 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 $95 
copayment for basic radiological services, including ultrasounds at an outpatient hospital.  
 
 The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay 
the allowed amount of $87.21, which is less than the $95 copayment for an ultrasound. An ultrasound falls 
within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 breast ultrasound provided on February 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional supplies or staff time (99072) provided December 
6, 2021 to December 27, 2021. 
 
You asked the Plan to pay for the additional supplies or staff time. You say that this service was medically 
necessary. The Plan denied your request. The Plan says this code is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 We find that CPT code 99072 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99072 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the additional supplies or staff time have not been met. Therefore, we decided that the Plan does not have to 
pay for additional supplies or staff time (99072) provided December 6, 2021 to December 27, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Darzalex for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says step therapy guidelines need to be followed. 
 
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 the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found based on the medical 
records provided, there is no indication that the enrollee has tried and failed the required drugs. Based on the 
medical records provided there is no indication that the plan's required drugs would likely be less effective 
and/or likely have adverse effects for the patient. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Darzalex for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740), and core build up (D2950) provided on 
September 9, 2021. 
 
You asked the Plan to pay for the dental services. You say that it was your understanding that the provider was 
in network. You say that you paid $602 out of pocket for the services. You say that you also received a bill 
requesting more money saying the provider was out of network. The Plan denied your request. The Plan says 
the claim denied correctly. 
 
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 and crowns are listed as covered, you pay 100% for dental services received out of network. Additionally, the core build up is not among those 
covered under this benefit, regardless of the provider's network status. Therefore, we decided that the Plan does 
not have to pay for the crown (D2740), and core build up (D2950) provided on September 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99212) rendered by the out-of-network 
(OON) provider on October 18, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without 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 has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the office visit (99212) rendered by the out-of-network (OON) provider on  
October 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an at-home COVID-19 test received on December 20, 2021. 
 
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 there is coverage for this prior to January 15, 2022. 
 
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, the services, was requested solely for screening purposes. Medicare does not cover this test prior to January 15, 2022. Additionally, Medicare does not reimburse separately for sales tax. 
Therefore, we decided that the Plan does not have to pay for an at-home COVID-19 test received on December 
20, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Medtronic Infuse BMP Allograft 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 the clinical value and effectiveness of the Infuse BMP Allograft in 
the setting of posterolateral lumbar spine fusion surgery with the Globus Creo rods and screws have not been 
demonstrated in the peer-reviewed literature. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. There is limited 
published, large-scale, long-term peer-reviewed literature that shows this request to be an effective and/or safe 
treatment for the noted pathology. There is no compelling rationale presented or extenuating circumstances 
noted to support the medical necessity of this request as an exception to guidelines. Our physician reviewer 
found that the enrollee's condition does not meet 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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve Medtronic Infuse BMP Allograft for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special anesthesia services provided on October 20, 2021, 
billed with code 99100. 
 You asked the Plan to pay for the special anesthesia services as billed. You say that the records support 
payment for these services. The Plan denied your request. The Plan says all services were approved for 
payment other than 99100 which is bundled in payment for other services. 
 
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 find that CPT code 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the special anesthesia services as billed have not been met. Therefore, we decided that the Plan does not 
have to pay for the special anesthesia services provided on October 20, 2021, billed with code 99100.