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

 
We decided that the Plan does not have to waive the copayment for laboratory diagnostic provided on July 18, 
2022. 
 
You asked the Plan to waive the copayment for laboratory diagnostic. You say that you felt there should be no 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $15 
copayment for outpatient diagnostic tests/laboratory tests.  
 
You have been asked to pay a $15 copayment for laboratory diagnostic. This item/service falls within the 
outpatient diagnostic tests/laboratory tests benefits 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 laboratory diagnostic provided on July 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that these items are necessary for your 
condition. The Plan denied your request. The Plan says both Medicare and the Plan do not provide coverage for 
this equipment. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an auricular stimulator.

You asked the Plan to pre-approve the stimulator. You say that this is not a spinal cord stimulator, PSTIM, nor is it considered acupuncture. The Plan denied your request. The Plan says this technology is still considered experimental and investigational.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

Medicare does not consider this request to be medically reasonable or necessary at this time. Based on this information, we decided that Medicare rules for coverage of the stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve an auricular stimulator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve tie down hardware for four-point strap system and R-net 
LCX color remote joystick. 
 
You asked the Plan to pre-approve tie down hardware for four-point strap system and R-net LCX color remote 
joystick. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the 
requested items are not separately reimbursable. 
 
The Plan must follow Medicare rules. Medicare rules say that wheelchair accessories are only covered for 
certain indications. 
 
We looked at the file and Medicare rules. The requested tie down hardware comes included with the base code 
and cannot be billed separately. The requested joystick is included in the base code and cannot be billed 
separately. Based on this information, we decided that Medicare rules for coverage of tie down hardware for 
four-point strap system and R-net LCX color remote joystick have not been met.  Therefore, we decided that the Plan does not have to pre-approve tie down hardware for four-point strap system 
and R-net LCX color remote joystick.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mandibular partial denture (D5214) provided by a 
participating provider on May 19, 2022. 
 
You asked the Plan to pay for a mandibular partial denture. You say that you believe the Plan should pay for 
this. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 70% 
coinsurance for partial dentures/in-network.  
 
You have been asked to pay a 70% coinsurance of the allowed amount for a mandibular partial denture. The 
total allowed amount is $1,112.00. The total amount you are being asked to pay is $778.40 ($1,112 x 70% = 
$778.40). This item/service falls within the partial dentures/in-network 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 pay for a mandibular partial denture (D5214) provided by a participating provider on May 19, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the therapeutic parenteral drug (D9610). 
 
You asked the Plan to pre-approve the dental service. You say that you are appealing the denied dental service. 
The Plan denied your request. The Plan says the denial of authorization for this service is correct, because 
therapeutic parenteral drugs are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, 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 the 
therapeutic parenteral drug (D9610).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite - one surface, posterior tooth #5 
(D2391) provided on July 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that all you know is that according to your Plan, 
fillings are covered 80% DN, and 20% your copayment. The Plan denied your request. The Plan says your 
benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service September 15, 2020. 
Therefore, we decided that the Plan does not have to pay for a resin-based composite - one surface, posterior 
tooth #5 (D2391) provided on July 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Lucence LiquidHALLMARK (liquid biopsy test) 
provided on February 4, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not medically 
necessary. 
 
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 testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the literature states that the liquid biopsy field in prostate cancer ( PCa) has advanced exponentially, 
developing prognostic and predictive biomarkers and holding promise for a minimally invasive approach of 
monitoring tumor evolution. In this review, we described urinary and circulating biomarkers based on CTC, RNA and DNA as novel tools to improve the characterization and the treatment of PCa patients. These liquid 
biopsy biomarkers show the potential to gain comprehensive information on PCa genetic landscape, and give 
information about the metastatic sites. Liquid biopsy could guide therapeutic decisions and accelerate the 
development of precision medicine in PCa. The recent advancement of molecular biology techniques available 
will bring to the development of new standardized liquid biopsy tests with high sensitivity and specificity, and 
lower cost that could promote the diffusion of liquid biopsy in routine clinical practice. Designing a dynamic 
therapeutic strategy based on tumor features detected in real-time through the liquid biopsy could significantly 
improve the survival rate and the quality of life of PCa patients. Remarkably, nucleic acids extracted from 
biological fluids play a crucial role in the clinical management of PCa patients. Among conventional body 
fluids, peripheral blood still remains the most suitable source of nucleic acids, because a wide series of 
literature data critically evaluate the preclinical and analytical issues for blood-derived nucleic acids. 
Conversely, little was known about the use of nucleic acids purified from urine samples. However, due to their 
close connection with prostatic glands, further studies should be performed to evaluate the clinical meaning of 
biomarkers from urine samples. As such, the requested Lucence LiquidHALLMARK test at issue in this case is 
not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the Lucence LiquidHALLMARK (liquid biopsy test) provided on February 4, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home sleep test device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that you are known to have severe obstructive sleep apnea, based on an attended polysomnography in 
2018. Positive airway pressure (PAP) titration showed that continuous positive airway pressure (CPAP) was 
effective. The current complaint appears to be difficulty sleeping, but there is no complete sleep history or 
Epworth score. It is not clear whether the problem is difficulty initiating sleep, maintaining sleep, or 
both. Sleep hygiene is not addressed. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a home sleep test device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hearing test and hearing aids with an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve the OON hearing test and hearing aids. You say that you have been without 
a hearing aid and that this is affecting your health. You say that you have been having a lot of problems with 
the Plan's network hearing aid provider. The Plan denied your request. The Plan says there are network 
providers who can supply the requested services and who has appointment availability. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids and hearing tests only when supplied through a specific provider. 
 
We looked at the file and the Plan's rules. The records show that the provider you are requesting is not the 
network provider the Plan offers coverage through. Based on this information, we decided that the Plan's rules 
for coverage of hearing test and hearing aids have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a hearing test and hearing aids with an out of network (OON) provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for 2 units of code 95886 provided on April 7, 2022. 
 
You asked the Plan to pay for 2 units of code 95886. The Plan denied your request. The Plan says that only one 
unit of this code is supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
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 2 units of code 95886 Our reviewer says that 
2 units of code 95886 is supported by the records provided. Our physician reviewer found that the records 
shows that the nerve study was conducted on both the left and right upper extremities. As such, 2 units of 
95886 is appropriate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 2 units of code 95886 have been met. Therefore, we decided that the Plan has to 
pay for 2 units of code 95886 provided on April 7, 2022.  
 
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power
options.
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied
your request. The Plan says there is no medical need for power options included with this power wheelchair.
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.
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 wheelchair. Our reviewer says that
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found that the
provided records do not support that the patient is high risk for skin breakdown, has a history of pressure
ulcer(s) or has had skin flap surgery. Records do not document the patient performs bladder self-catheterization
and is unable to transfer independently or that the patient has increased muscle tone or spasticity to meet
criteria for the power tilt and recline feature. Records do, however, document edema for which the power
elevating leg rest/platform has been requested. As the patient meets criteria for one power option but not
multiple power options, the requested group 3 power wheelchair with multiple power options does not meet
criteria for 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 wheelchair have not been met. Therefore, we decided that the Plan does not
have to pre-approve a group 3 power wheelchair with multiple power options.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay an additional amount for inpatient hospital services provided on January 
10, 2022, through January 26, 2022. 
 
You asked the Plan to pay an additional amount for the inpatient hospital services. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says that the 
documentation submitted does not support the services billed. 
 
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 forwarded any evidence to indicate what specific 
services have been denied. The documentation submitted does not include the audit findings showing which 
services are considered bundled in the room and board charges. It is the burden of the Health Plan to 
substantiate their denial with evidence. In this case, the Plan's denial has not been substantiated so we must find 
in your favor. Therefore, we decided that the Plan has to pay an additional amount for inpatient hospital 
services provided on January 10, 2022, through January 26, 2022.  
 
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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for an unlisted nervous system procedure (procedure code 64999) provided 
to the enrollee on April 28, 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 that modifier 50 would not be appropriate for CPT 64999. 
 
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 64999 is "Unlisted procedure, nervous system." 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that anesthesia report includes 
documentation of a bilateral ultrasound guided Quadratus Lumborum nerve block, requested from the surgeon 
for post operative pain management. In this case, 64999 is appropriate to report for this procedure as there is no 
CPT code for this procedure, as well as modifier 50 to indicate a bilateral procedure.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
an unlisted nervous system procedure (procedure code 64999) provided to the enrollee on April 28, 2022.  
 
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 drug testing provided on November 12, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for drug testing. You say that you are requesting reconsideration. The Plan denied your request. The Plan says if the enrollee receives care from an out-of-network provider (a provider who is not part of our plan's network), such services will not be covered unless the enrollee obtains a 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 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 drug testing provided on November 12, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and related 
supplies. 
 
You asked the Plan to pre-approve the CGM and related supplies. You say that you have vision problems and 
difficulties pricking your fingers. You say that you have diabetes and take Humulin insulin 3 times a day or 
every time you eat. You say that you test your blood glucose several times a day. You say that you have been 
without testing for weeks now. The Plan denied your request. The Plan says the criteria 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. The only medical records provided show that the enrollee takes insulin twice 
a day and the note doesn't mention a sliding scale. Based on this information, we decided that Medicare rules 
for coverage of the CGM and related supplies have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a continuous glucose monitor (CGM) and related supplies.