Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
You asked the Plan to pre-approve the compression stockings. You say that this is medically necessary. The
Plan denied your request. The Plan says this is verified to not be a covered benefit.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are
noncovered because they do not meet the statutory definition of a surgical dressing.
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab testing provided on May 13, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the panel was not ordered by the enrollee's oncology team.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
The file shows that circulating tumor cell testing was provided. We looked at the file, and Medicare rules. No
data has been forthcoming to demonstrate improved patient outcomes, or that the assay changes physician
management to demonstrate improved patient outcomes. Based on this information, we decided that Medicare
rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to
pay for the lab testing provided on May 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug injection provided on August 11, 2021.
You asked the Plan to waive the coinsurance for a Medicare Part B drug injection. You say that you thought that you were switching to a better Plan and cannot afford the charges nor take any other supplement. 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 20% coinsurance for Medicare Part B prescription drugs. You received a Medicare Part B drug injection on August 11, 2021. The total allowed amount is $1,321.24 and
20% of that is $264.25. You have been asked to pay the total coinsurance amount of $264.25 for a Medicare Part B drug injection. A Medicare Part B drug injection 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 a Medicare Part B drug injection provided on August 11, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy to be provided by the requested out-of-network provider.
You asked the Plan to pre-approve physical therapy. You say that you require your walker for safety, and you are unable to put your walker in and out of your car. The Plan denied your request. The Plan says we will not authorize medically necessary care outside the health Plan network unless that care is not available within the 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physical therapy to be provided by the requested out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office visits (99215, 99245) with a provider that does not
participate in Medicare.
You asked the Plan to pay for office visits. You say that you need this provider's expertise. The Plan denied
your request. The Plan says these services are available in-network.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is
not enrolled in the Medicare program.
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare
program. Therefore, we decided that the Plan does not have to pay for office visits (99215, 99245) with a
provider that does not participate in Medicare.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildup (D2950).
You asked the Plan to pre-approve core buildup (D2950). You say that the dentist advised this is necessary because of a rotten part that needs buildup. The Plan denied your request. The Plan says the service 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 pre-approve core buildup (D2950).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on March 8, 2021 by a non-network provider.
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 rendered by a non-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 requested provider in this case is not a network provider with the Plan. The referring provider 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 laboratory services provided on March 8, 2021 by a non-network provider.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyalgan.
You asked the Plan to pre-approve Hyalgan. You say that the medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 Hyalgan. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the record does not indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's preferred step one alternative. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Hyalgan have not been met. Therefore, we decided that the Plan does not have to pre-approve Hyalgan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an occlusal guard (D9945) provided by an out-of-network provider on May 6, 2021.
You asked the Plan to pay for an occlusal guard. You say that you assumed that all your dental services would be covered. The Plan denied your request. The Plan says D9945 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 for an occlusal guard (D9945) provided by an out-of-network provider on May 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment provided on May 5, 2021.
You asked the Plan to pay for the services provided. You say that the device was for use during surgery. The Plan denied your request. The Plan says payment would have been included in the facility payment.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Medicare rules say that CMS does not pay any provider or supplier other than the facility for services furnished to a beneficiary.
The file shows that the items at issue were provided during surgery services at an ambulatory surgical center. We looked at the file and the rules. The facility must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. This service was provided via arrangement of the facility. Payment for this service would have been included under the facility claim. Payment to you for this service is the responsibility of the facility. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the durable medical equipment provided on May 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory service (88112) rendered by an out-of-network (OON) provider on August 12, 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. You are 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 laboratory service (88112) rendered by an out-of-network (OON) provider on August 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for DME provided on July 21, 2021.
You asked the Plan to waive the deductible for DME. You say that you feel that the charges are way too high for a device you could have spent $100 on. You also state that you were not informed that you would owe deductible charges. 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. Your contract with the Plan says that there is a $500 deductible which applies to DME and related supplies. You received DME on July 21, 2021. The record shows that you had paid $0 toward the $500 deductible prior to receiving the services. Therefore, you are responsible to pay the allowed amount of $380.02. The item or service you asked the Plan to waive the deductible for falls within the benefit category DME and related supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible which applies to DME and related supplies. This cost sharing is a contractual obligation that had not
been met at the time DME was received on July 21, 2021. Therefore, we decided that the Plan does not have to waive the deductible for DME provided on July 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Injectafer.
You asked the Plan to pre-approve Injectafer. You say that the medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Injectafer. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the documentation does not support that the Injectafer is medically reasonable and necessary or safe and effective for you. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have to pre-approve Injectafer.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), periapical x-ray (D0220), and unspecified preventive service (D1999) provided on October 2, 2020.
You asked the Plan to pay for the dental services. You say that the services you received are covered. You say that you were advised by a plan representative that the provider in this case was in network. You say that The Plan denied your request. The Plan says the limited oral evaluation and unspecified preventive service are not listed as covered service. The Plan says you were advised in June 2021 that the provider in this case was in network as of January 1, 2021. The Plan says that the provider was out of network on the date of service in this case. The Plan also says that dental services received out of network are not covered.
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 and periapical x-ray is listed as
covered, dental services received out of network are not covered. Additionally, the limited oral evaluation and
periapical x-ray are 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 limited oral evaluation (D0140), periapical xray
(D0220), and unspecified preventive service (D1999) provided on October 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a radiofrequency ablation procedure of the lower back.
You asked the Plan to pre-approve a radiofrequency ablation. You say that the requested service is a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the requested procedure have not been met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve a radiofrequency ablation. Our reviewer
says that the requested services are not considered medically reasonable and necessary in this case. Our
physician reviewer found that more than a year has lapsed between diagnostic sets and a second set of
diagnostic MBBs should be repeated. Moreover, the utilization limitation is exceed by this request.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a radiofrequency ablation have not been met. Therefore, we decided that the
Plan does not have to pre-approve a radiofrequency ablation procedure of the lower back.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve tomotherapy 3D with image-guided radiation therapy (IGRT).
You asked the Plan to pre-approve tomotherapy 3D with IGRT. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve tomotherapy 3D with IGRT. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record do not demonstrate why standard 2D radiation without IGRT would be insufficient in this patient with widespread metastatic disease. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of tomotherapy 3D with IGRT have not been met. Therefore, we decided that the Plan does not have to pre-approve tomotherapy 3D with image-guided radiation therapy (IGRT).
Appeal type: Outpatient Therapies
Decision: Unfavorable

decided that the Plan does not have to pay for the additional supplies and materials provided from
December 18, 2020, through December 30, 2020.
You asked the Plan to pay for the additional supplies and materials. You say that 99072 was established to
report additional practice expenses during a Public Health Emergency including supplies and additional clinical
staff time. You say that the claims should be reprocessed. The Plan denied your request. The Plan says bundled
services are not eligible for separate reimbursement.
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 99072 is additional supplies, materials, and clinical staff
time over and above those usually included in an office visit or other non-facility service(s), when performed
during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease.
We find that CPT code 99072 is not supported in the medical record. Specifically, CPT code 99072 has a status
indicator of B. This means that CPT code 99072 is considered bundled and not separately payable. Based on
this information, we decided that Medicare rules for coverage of the additional supplies and materials have not
been met. Therefore, we decided that the Plan does not have to pay for the additional supplies and materials
provided from December 18, 2020, through December 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for FoundationOne testing (81455) provided on June 4, 2021.
You asked the Plan to pay for FoundationOne testing. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that genetic testing procedures submitted under code 81455 are unlikely to impact therapeutic decision-making in the clinical management of the patient and will be denied automatically as not medically necessary. We looked at the file and Medicare rules. The testing at issue is unlikely to impact therapeutic decision-making. Based on this information, we decided that Medicare rules for coverage of FoundationOne testing have not been met. Therefore, we decided that the Plan does not have to pay for FoundationOne testing (81455) provided on June 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transarterial hepatic internalradiation therapy.
You asked the Plan to pre-approve transarterial hepatic internalradiation therapy. You say that the services are
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore,
coverage criteria have not been met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve transarterial hepatic internalradiation
therapy. Our reviewer says that the requested items/services are not considered medically reasonable and
necessary in this case. Our physician reviewer found the treatment offered would not be furnished in
accordance with accepted standards of medical practice when other more standard options could be considered.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of transarterial hepatic internalradiation therapy have not been met. Therefore, we
decided that the Plan does not have to pre-approve transarterial hepatic internalradiation therapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse the in network rate for the root canal (D3310), core build up (D2950), and retreatment of a previous root canal (D3346) provided from July 9, 2021, to July 19, 2021.
You asked the Plan to reimburse the in network rate for the dental services. You say that you were advised you may have an infection on an older root canal. You say that your dentist referred you to a specialist for further evaluation. You say that if this was not treated it would affect the jaw causing major surgery. You also say that this should be covered as preventive medicine. The Plan denied your request. The Plan says there is an annual maximum of $3,000 for covered dental services. The Plan says that the annual maximum has been exhausted. The Plan also says that core build up 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 annual maximum benefit has been
exhausted.
Date of Service Plan Paid Date Plan Paid
4/21/2021 $302 5/4/2021
6/16/2021 $293 6/22/2021
6/28/2021 $978 7/14/2021
7/19/2021 $241 11/9/2021
7/22/2021 $1,186 8/12/2021
TOTAL: $3,000
Additionally, the core build up is not among those covered under this benefit. Therefore, we decided that the
Plan does not have to reimburse the in network rate for the root canal (D3310), core build up (D2950), and
retreatment of a previous root canal (D3346) provided from July 9, 2021, to July 19, 2021.