Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing visits. 
 
You asked the Plan to pre-approve the visits. You say that the enrollee has vascular dementia which he has 
cognitive difficulty and poor memory recall. The enrollee would benefit from physical therapy or occupational 
therapy. The Plan denied your request. The Plan says the services are not medically necessary. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 visits. Our reviewer says that the 
services are not medically reasonable and necessary. Our physician reviewer found the enrollee does not have 
documented skilled nursing needs. The requested services appear to be custodial. As such, the requested home 
health services are not medically necessary or reasonable. 
 
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 visits have not been met. Therefore, we decided that the Plan does not have 
to pre-approve home health skilled nursing visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on July 11, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these services are not 
included in the dialysis rate. The Plan denied your request. The Plan says Medicare does not separately pay for 
ESRD-related laboratory testing. 
 
 
 
 
 
 The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory 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 related to end-stage renal disease (ESRD) provided on July 11, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for diagnostic services provided on July 15, 
2022. 
 
You asked the Plan to waive the cost share for diagnostic services. You say that you are disputing the share 
cost. 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 $60 
copayment, $25 copayment and 20% coinsurance for outpatient diagnostic tests and therapeutic services and supplies. The allowed amount of a diagnostic service total $339.20, resulting in a coinsurance amount of 
$67.84.  
 
You have been asked to pay $152.84 cost share for diagnostic services. These items/services fall within the 
outpatient diagnostic tests and therapeutic services and supplies benefit categories. 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 cost share for diagnostic services provided on July 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a third level of injection provided to the enrollee on June 7, 
2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the provider did not send in any evidence of a unique circumstance for more levels. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the enrollee's provider did not provide evidence of unique circumstances for a third level 
with sufficient documentation of medical necessity on appeal.  The requested procedure 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for a third level of injection provided to the enrollee on June 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing billed with code 0037U provided on 
September 29, 2021. 
 
You asked the Plan to pay for code 0037U. You say that the testing was medically necessary. The Plan denied 
your request. The Plan says the claim for this molecular pathology testing did not include the required unique 
identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. 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 genetic testing billed with code 0037U 
provided on September 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you cannot go home with the wound 
vacuum-assisted closure. You say that you must be in an LTACH while on the wound vacuum-assisted closure 
for the wound to heal. You say that without that care you are at risk for losing your leg. The Plan denied your 
request. The Plan says an LTACH admission is not medically necessary, and you can safely receive the care 
you need in the current hospital setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that you are more stable and should only require short-term additional acute care 
services that can safely be administered at the current facility. You do not require services at the LTACH that 
are not already available at the current facility. 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory service (CPT code 81540) provided on January 19, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that the service is necessary. The Plan denied 
your request. The Plan says that they did not have all information to consider the claim and then they were 
untimely with appeal. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 pay for the laboratory service. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found consider tumor/somatic molecular profiling for patients who are candidates for anti-cancer 
therapy to identify uncommon mutations (i.e., RET fusions). Testing on tumor tissue is preferred; however, 
cell-free DNA testing can be considered if tumor tissue testing is not feasible. 
 
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 laboratory service have been met. Therefore, we decided that the Plan has to 
pay for the laboratory service (CPT code 81540) provided on January 19, 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 an unspecified removable prosthodontic procedure (D5899 
x2) provided on September 7, 2022. 
 
You asked the Plan to pay for the unspecified removable prosthodontic procedure (D5899 x2). You say that 
you are requesting reconsideration of the claim. The Plan denied your request. The Plan says this service is not 
covered under the benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
unspecified removable prosthodontic procedure (D5899 x2) provided on September 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a NeuroTrax comprehensive testing suite. 
 You asked the Plan to pre-approve a NeuroTrax comprehensive testing suite. You say that a NeuroTrax 
comprehensive testing suite is medically necessary. The Plan denied your request. The Plan says the requested 
NeuroTrax comprehensive testing suite does not meet the Medicare coverage criteria. 
 
The Plan follows Medicare rules.  
 
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 NeuroTrax comprehensive testing 
suite. Our reviewer says that a NeuroTrax comprehensive testing suite is not medically necessary. Our 
physician reviewer found the requested service(s) in this case are standardized batteries of tests which the LCD 
generally states, "are not acceptable". Therefore the service would not meet the LCD requirements 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 a NeuroTrax comprehensive testing suite have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a NeuroTrax comprehensive testing suite.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anti-reflective coating (V2750), photochromatic tint 
(V2744), and vision item or service (V2799) provided on May 16, 2022. 
 
You asked the Plan to pay for the anti-reflective coating, photochromatic tint, and vision item or service. The 
Plan denied your request. The Plan says you purchased additional add-ons which are not considered reasonable 
and medically necessary. 
 
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 one pair of eyeglasses with standard frames. 
 
 
 
 We looked at the file and the Plan's rules. The record shows that you purchased upgraded lenses, which are not 
covered under your plan. Based on this information, we decided that the Plan's rules for coverage of the anti-
reflective coating, photochromatic tint, and vision item or service have not been met. Therefore, we decided 
that the Plan does not have to pay for the anti-reflective coating (V2750), photochromatic tint (V2744), and 
vision item or service (V2799) provided on May 16, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service September 
23, 2022. 
 
You asked the Plan to pay for procedure code 76641. You say that this should be paid for. The Plan denied 
your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.   
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service September 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 12, 2022, billed with 
codes 81194, 81301, 81455, and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that the testing was medically necessary. 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 
May 12, 2022, billed with codes 81194, 81301, 81455, and 81479.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hearing aids to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the hearing aids. You say that you found hearing aids that are cheaper at the 
OON provider's office, and they help you exactly the same as the overpriced hearing aids that are offered in-
network. The Plan denied your request. The Plan says the requested service can be administered by in-network 
providers, therefore the request for OON hearing aids remains denied. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
hearing aids to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction (92015) provided on August 2, 2022. 
 
You asked the Plan to pay for the refraction. You say that you were not advised that the exam would not be 
covered, and you did not go for glasses. The Plan denied your request. The Plan says this service is not 
covered. The Plan also says that you signed a notification of non-covered services form at the provider's office 
which states a refraction service is not covered, and you would be responsible for the charge. 
 
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 these services when it is performed as part of a routine vision eye exam. 
 
We looked at the file and the Plan's rules. The record shows you signed a Notification of Non-Covered Services 
form at the provider's office which shows you acknowledged a refraction service is not covered, and you would 
be responsible for the charge. Based on this information, we decided that the Plan's rules for coverage of the 
refraction have not been met. Therefore, we decided that the Plan does not have to pay for the refraction 
(92015) provided on August 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no documentation using the same scale that there has been at least 50% 
improvement in pain relief for three months. 
 
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 injection. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee underwent an epidural steroid injection (ESI) on 11/7/22, as of 12/28/22 had 
experienced greater than 50% relief that has been ongoing for over six weeks. A repeat injection is not 
indicated at this time. The relief has only been sustained for six to seven weeks. here is no documentation that a 
different approach or medication will be utilized for the requested repeat cervical ESI. The records show that 
neither improvement in pain relief and/or improvement in function measured from baseline using the same 
scale were or have been sustained for at least three months as required. 
 
 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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat epidural steroid injection.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on June 25, 
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 Medicare says screening services performed for a purpose other than treatment or diagnosis of a 
specific illness, symptoms, complaint, or injury are excluded from coverage. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there was no specific clinical rationale for the obtained laboratory studies. The review has 
determined that the services at issue in this case are 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for laboratory services provided to the enrollee on June 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foam wound dressings. 
 
You asked the Plan to pre-approve the dressings. You say that this is medically necessary. The Plan denied 
your request. The Plan says the records do not have an indication of moderate to heavy drainage. 
 
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 dressings. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that at the time of denial, the wound only had scant draining. This request would be considered 
not medically 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 dressings have not been met. Therefore, we decided that the Plan does not 
have to pre-approve foam wound dressings.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction (92015) provided on August 4, 2022. 
 
You asked the Plan to pay for the refraction. You say that this should be covered under your medical as 
preventive care due to your diabetes. The Plan denied your request. The Plan says this service is not covered 
under your plan. 
 
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 these services when it is performed during a routine vision exam. 
 
We looked at the file and the Plan's rules. The record shows that you received a medical eye exam for diabetes, 
and not a routine exam. Based on this information, we decided that the Plan's rules for coverage of the 
refraction have not been met. Therefore, we decided that the Plan does not have to pay for the refraction 
(92015) provided on August 4, 2022.