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

 
We decided that the Plan does not have to pay for a screening mammogram provided on December 23, 2022. 
 
You asked the Plan to pay for a screening mammogram. You say that you do not agree with the denial of this 
service. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a screening 
mammogram provided on December 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on September 20, 
2022. 
 
You asked the Plan to pay for the dental service. You say that you were referred to the provider for a medical 
issue and they never done an evaluation before. 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 the date of service of January 6, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
September 20, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiological services provided on December 7, 2022. 
 
You asked the Plan to pay for the radiology services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim 
and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on January 5, 2023. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the radiology services provided have not been met. Therefore, we decided that the Plan does not have to pay for radiological services provided on 
December 7, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on September 07, 2022, to 
November 23, 2022. 
 
You asked the Plan to pay for psychotherapy. You say that this service is supported in the records. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for psychotherapy provided 
on September 07, 2022, to November 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve autologous blood concentrate product (D7921) x2 and 
collection and application of autologous blood concentrate product (D7953). 
 
You asked the Plan to pre-approve dental services. You say that you need the requested services in order to 
prevent further issues. The Plan denied your request. The Plan says this service is not covered under your 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. . Autologous blood 
concentrate product (D7921) and collection and application of autologous blood concentrate product (D7953) 
are not covered under the Plans dental benefits. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D7921 and D7953 are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
autologous blood concentrate product (D7921) x2 and collection and application of autologous blood 
concentrate product (D7953).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for shoulder x-rays provided on October 13, 2022. 
 
You asked the Plan to pay for shoulder x-rays. You say that this provider was the closest and most convenient 
for the enrollee. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for shoulder x-rays provided 
on October 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a complete denture - maxillary (D5110) 
provided on October 20, 2022. 
 
You asked the Plan to waive the coinsurance for the complete denture - maxillary. You say that you received a 
notice that the claim  was turned down because of the missing dental code. You also say that the Plan now has 
the correct code. 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 75% 
coinsurance for a complete denture - maxillary (upper) or mandibular (lower) provided out-of-network. You 
may be billed by the out-of-network provider for any charged amount greater than the payment made by the 
Plan. 
 
You have been asked to pay a 75% coinsurance for the complete denture - maxillary. This service falls within 
the major dental services provided out-of-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 waive the 
coinsurance for a complete denture - maxillary (D5110) provided on October 20, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on March 8, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed with a correct HIPPS rate 
code. 
 
The Plan follows Medicare rules. The rules say that home health claims must be submitted with correct HIPPS 
rate code.  
 
We reviewed the file and the Medicare rules. We find that the claim was not submitted with a correct HIPPS 
rate code. Based on this information, we find that the Medicare rules for payment of the claim at issue have not 
been met. Therefore, we decided that the Plan does not have to pay for the home health services provided on 
March 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and a cleaning 
(D1110) provided on November 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told the cleaning would be covered 
and you were given the wrong information. The Plan denied your request. The Plan says your maximum 
benefit for the year 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 on March 14, 2022, the Plan paid $102 for dental services. On April 26, 2022, the Plan paid $898 for 
dental services. For the year of 2022 the Plan paid $1,000 ($102 paid + $898 paid) for dental services; 
therefore, your benefit for the year of 2022 was exhausted on the date of service of April 26, 2022. Therefore, 
we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and a cleaning 
(D1110) provided on November 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on November 02, 2022. 
 
You asked the Plan to pay for laboratory services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory services 
provided on November 02, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Doxil. 
 
You asked the Plan to pre-approve Doxil. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug is not medically necessary. 
 
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 Doxil. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has a diagnosis of advanced endometrial adenocarcinoma. Based on the medical 
records provided, the guidelines of the National Comprehensive Cancer Network and the Medicare-approved 
major drug compendia there is no documentation that the Doxil in combination with carboplatin at issue in this 
case meets all Medicare criteria for safe and effective for the patient. The guidelines of the National 
Comprehensive Cancer Network and the Medicare-approved major drug compendia do not support the Doxil in 
combination with carboplatin in the clinical scenario described in this case - advanced endometrial 
adenocarcinoma with prior treatment with surgery, cisplatin, Keytruda and Lenvima. Therefore, the enrollee 
does not meet criteria for the requested drug.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Doxil have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Doxil.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on October 21, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says this was not authorized. 
 
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 laboratory services provided on October 21, 2022, 
by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility  care provided on September 09, 2022. 
 
You asked the Plan to pay for nursing facility  care. You say that the services were medically necessary. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for nursing facility  care 
provided on September 09, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99292 billed for date of service November 4, 
2022. 
 You asked the Plan to pay for procedure code 99292. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 99292 is bundled into payment for codes 36620 and 
36556. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 99292 
is a column II code to column I codes 36620 and 36556. This claim has not been billed with an appropriate 
modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 99292 billed for date of service 
November 4, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for debridement services provided on August 30, 2022. 
 
You asked the Plan to pay for debridement services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for debridement services 
provided on August 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services. 
 
You asked the Plan to pre-approve the dental services. You say that you would like to request reconsideration 
of the denied authorization. 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 February 15, 2022. 
Therefore, we decided that the Plan does not have to pre-approve the dental services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient surgery provided on July 21, 2022. 
 
You asked the Plan to pay for an outpatient surgery. You say that you belived you were in-network. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an outpatient surgery 
provided on July 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 20, 2022, billed 
with codes 81334, 81403, 81405, 81347, 81176, 81270, 81279, 81338, 81219, 81120, 81121, 81245, 81246, 
81310, 81272, 81218, and G0452. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
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 
September 20, 2022, billed with codes 81334, 81403, 81405, 81347, 81176, 81270, 81279, 81338, 81219, 
81120, 81121, 81245, 81246, 81310, 81272, 81218, and G0452.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the anesthesia services provided on May 24, 2022. 
 
You asked the Plan to pay for the anesthesia services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says that the incorrect modifier was 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. Review of the file shows that the Plan states that an incorrect modifier was used. 
However, the documentation does not include an explanation on why the modifier used is incorrect. No other 
denial rationale was provided. The Plan did not substantiate their denial. Therefore, we decided that the Plan 
has to pay for the anesthesia services provided on May 24, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous ablation therapy, stab phlebectomy, and 
ligation of perforator vein(s) with ultrasound guidance. 
 
You asked the Plan to pre-approve endovenous ablation therapy, stab phlebectomy, and ligation of perforator 
vein(s) with ultrasound guidance. You say that you disagree with the Plan's denial. The Plan denied your 
request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that treatment for varicose veins is only covered for 
certain indications. 
 
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 endovenous ablation therapy, stab 
phlebectomy, and ligation of perforator vein(s) with ultrasound guidance. Our reviewer says that the 
documentation does not support that the requested services are medically reasonable or necessary. Our 
physician reviewer found in order to meet coverage criteria, and for the procedure to be considered medically 
necessary, the enrollees symptoms have to be attributable to the veins to be treated.  It is not possible to 
attribute the enrollees symptoms to the varicose veins (or the appropriateness of ablations of remaining 
superficial veins) without an assessment of arterial perfusion particularly in this enrollee with leg symptoms 
requiring chronic analgesic medication recalcitrant to compression stockings and leg elevation.  Additionally, the materials provided do not include source documents of the lower extremity venous duplex. 
Therefore, the enrollee does not meet criteria for the requested 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 endovenous ablation therapy, stab phlebectomy, and ligation of perforator 
vein(s) with ultrasound guidance have not been met. Therefore, we decided that the Plan does not have to pre-
approve endovenous ablation therapy, stab phlebectomy, and ligation of perforator vein(s) with ultrasound 
guidance.