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

 
We decided that the Plan does not have to pre-approve knee replacement surgery. 
 
You asked the Plan to pre-approve knee replacement surgery. 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 knee replacement surgery. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found detailed documentation is not evident regarding trial and failure of recent, reasonable, 
and comprehensive less invasive conservative care measures. Additionally, the imaging studies do not 
corroborate significant osteoarthritis in the left knee. There are limited large-scale, long-term references 
showing the safety and efficacy of the requested surgery in this clinical setting. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception to guidelines. Therefore, the requested left knee replacement surgery, 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 knee replacement surgery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve knee replacement surgery.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 22, 2021, billed with 
codes 81201 and 81317. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says the 
services were billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
June 22, 2021, billed with codes 81201 and 81317.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services received in the 2022 Plan year. We decided that the Plan 
does not have to pay for the services received in the 2021 Plan year.  
 
You asked the Plan to pay for the outpatient services. You say that you do not know why these claims are not 
being paid. The Plan says that prior authorization was not obtained for the services received. 
 
We decided that the Plan has to pay for the services received in the 2022 Plan year.  
 
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 full 2022 Evidence of Coverage was not received. This means 
that we could not determine if authorization was required for out-of-network services. Therefore, we decided 
that the Plan has to pay for the services received in the 2022 Plan year.  
 
We also decided that the Plan does not have to pay for the services received in the 2021 Plan year. 
 
The requested provider for the services received in 2021 is not a network provider with the Plan. 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 services provided in the 2021 
Plan year. 
 
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 therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that a CGM is medically necessary for your 
difficult to manage blood sugar levels. 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 you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic 
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic 
continuous glucose monitor (CGM).
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the COVID-19 tests purchased on January 14, 2022. 
 
You asked the Plan to pay for the COVID-19 tests. You say that you received a letter advising tests would be 
covered even if they were purchased from a non-contracted supplier. The Plan denied your request. The Plan 
says that this test was not covered at the time it was purchased. 
 
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. The Plan did not verify that you had a reasonable way of knowing when the 
Plans supplemental benefit for at-home COVID-19 test kits would start. There is no way of verifying that any 
COVID-19 testing information which shows the way to find out about the additional at-home testing benefit 
was provided to you, as the full 2022 Evidence of Coverage does not contain any information about at-home 
COVID testing. The Evidence of Coverage also does not refer you to the Plan's website to find coverage 
information for at-home COVID-19 testing. You had no way of knowing that the Plans supplemental benefit 
started later than January 15, 2022. Therefore, we decided that the Plan has to pay for the COVID-19 tests 
purchased on January 14, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid services provided on February 3, 2022 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the hearing aid services. You say that it was an oversight that the provider's 
status was not verified, and you would like the hearing aids to be covered. The Plan denied your request. The 
Plan says hearing services must be provided by a contracted provider. 
 
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 only when they are provided by a contracted provider.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aid services have not been met. Therefore, we decided that the Plan does not have to 
pay for the hearing aid services provided on February 3, 2022 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
   
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not require treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy program at least three hours a day and five days 
a week, or 15 hours over seven consecutive days. You have had some functional decline from your baseline 
level of function, but it does not require the intensity of therapies provided on acute inpatient rehabilitation and 
you can receive therapy a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (0037U) provided on February 1, 
2022. 
 
You asked the Plan to pay for code 0037U. 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. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The gene panel provided includes the FANCC gene. In addition to 
single gene testing, MolDX will also deny panels of tests that include the FANCC gene. Based on this 
information, we decided that Medicare rules for coverage of code 0037U have not been met. Therefore, we 
decided that the Plan does not have to pay for the laboratory services (0037U) provided on February 1, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says that the requested admission to an IRF is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is found to be medically reasonable and necessary. Our physician reviewer found the 
clinical documentation shows that you have active comorbidities that would benefit from close medical 
monitoring on an inpatient setting. Evaluating therapists recommend intensive rehabilitation including physical 
therapy, occupational therapy, and speech therapy thus IRF criteria have been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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 provided on January 10, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says this claim has not been billed as required 
by Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services provided on January 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a reline complete maxillary denture (code D5750) provided 
on March 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that you do not understand how only one reline 
would be covered. The Plan denied your request. The Plan says your benefit for the requested item or service 
has already been exhausted. The Plan says you received the allowed frequency on the reline of the denture on 
this claim and received an additional reline at the same visit.  
 
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 March 23, 2022. 
Therefore, we decided that the Plan does not have to pay for a reline complete maxillary denture (code D5750) 
provided on March 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the massage therapy services provided on December 16, 
2021. 
 
You asked the Plan to pay for the massage therapy services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says massage therapy is not covered by 
Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pay for the massage therapy services provided on December 16, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (0037U) provided on December 29, 
2021. 
 
You asked the Plan to pay for code 0037U. 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. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The gene panel provided includes the FANCC gene. In addition to 
single gene testing, MolDX will also deny panels of tests that include the FANCC gene. Based on this 
information, we decided that Medicare rules for coverage of code 0037U have not been met. Therefore, we 
decided that the Plan does not have to pay for the laboratory services (0037U) provided on December 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 4, 2021. 
 
You asked the Plan to pay for the laboratory services. 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 state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services provided on October 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on January 3, 2022. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan 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 did not pre-approve the 
service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on January 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the contact lens fitting (92310) and hydrophilic contact 
lenses (V2520) provided on March 30, 2022. 
 
You asked the Plan to pay for the contact lens fitting and contact lenses. You say that contact lenses are 
medically necessary for you due to your medical condition. You also say a yearly prescription for contacts 
should be allowed for you. The Plan denied your request. The Plan says your vision benefit for contact lenses 
has been exhausted. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers contact lenses instead of lenses and frames every 2 years. 
 
We looked at the file and the Plan's rules. The record shows that the Plan paid for contact lenses on February 
24, 2021, and your benefit has been exhausted. Based on this information, we decided that the Plan's rules for 
coverage of the contact lens fitting and contact lenses have not been met. Therefore, we decided that the Plan 
does not have to pay for the contact lens fitting (92310) and hydrophilic contact lenses (V2520) provided on 
March 30, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the at-home COVID-19 test kits purchased on January 20, 2022. 
 
You asked the Plan to pay for the at-home COVID-19 test kits. You say that the government said that all 
insurance companies should reimburse for all home COVID-19 tests. The Plan denied your request. The Plan 
says that this was not a covered benefit at the time you purchased the kits. 
 
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. The Plan did not verify that the enrollee had a reasonable way of knowing when 
the Plans supplemental benefit for at-home COVID-19 test kits would start. There is no way of verifying that 
the COVID-19 testing information which shows the way to find out about the additional at-home testing 
benefit, was actually provided to the enrollee, as the full 2022 Evidence of Coverage does not contain any 
information about at-home COVID testing. The enrollee had no way to know that the Plans supplemental 
benefit started later than January 15, 2022. Therefore, we decided that the Plan has to pay for the at-home 
COVID-19 test kits purchased on January 20, 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: Unfavorable

 
We decided that the Plan does not have to pay for laboratory work provided on February 24, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory work. You say that the referring provider is your primary 
physician and has been for many years. The Plan denied your request. The Plan says no prior authorization was 
obtained. 
 
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 did not pre-approve the 
laboratory work. We found no exception that would require the Plan to pay for the laboratory work. The record 
shows the referring physician, and the rendering provider are out-of-network. Therefore, we decided that the 
Plan does not have to pay for laboratory work provided on February 24, 2022, by an out-of-network (OON) 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services for patient of extreme age (99100) 
provided on February 14, 2022. 
 
You asked the Plan to pay for the anesthesia services for patient of extreme age. You say that you would like 
this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no separate 
payment is ever made for this service. 
 
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 anesthesia services for patient of extreme age have not been met. Therefore, we decided that the Plan 
does not have to pay for the anesthesia services for patient of extreme age (99100) provided on February 14, 
2022.