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

 
We decided that the Plan does not have to pay for mass spectrometry and tandem mass spectrometry (83789) 
provided on June 14, 2021. 
 
You asked the Plan to pay for the mass spectrometry. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says an edit exists between appealed procedure 
codes 83789 and 80307. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the mass spectrometry have not been met. Specifically, we find that the testing described by the 
billed code is considered specimen validity testing which is not separately payable. Therefore, we decided that 
the Plan does not have to pay for mass spectrometry and tandem mass spectrometry (83789) provided on June 
14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for wound debridement services (11042) 
provided from August 19, 2021, to September 2, 2021. 
 
You asked the Plan to waive the copayment for the wound debridement services. You say that the services 
should be covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-
sharing applied correctly based on the services provided. 
 
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 $330 
copayment for Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers.  
 You have been asked to pay a $990 copayment for 3 wound debridement services ($330 x 3 = $990). Wound 
debridement services fall within the Outpatient Surgery and Other Medical Services Provided at Hospital 
Outpatient Facilities and Ambulatory Surgical Centers 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 copayment for wound debridement services (11042) provided from August 19, 2021, to September 2, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from 
November 1, 2021, to November 21, 2021. 
 
You asked the Plan to pay for the SNF care provided from November 1, 2021, to November 21, 2021. You say 
that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says the 
enrollee did not receive skilled care during the dates of service in this case. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care provided from November 1, 
2021, to November 21, 2021. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF 
care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the 
specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily 
skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional 
therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 
setting. 
 
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 SNF care provided from November 1, 2021, to November 21, 2021 have not 
been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care 
provided from November 1, 2021, to November 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dexamethasone 4 mg tablet. 
 
You asked the Plan to pre-approve Dexamethasone. You say that this drug is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the enrollee does not satisfy the criteria for 
oral anti-emetic drugs to be covered under the medical benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B as the provider has confirmed this drug is not to be initiated within 2 hours of the 
chemotherapy agent. Therefore, we decided that the Plan does not have to pre-approve Dexamethasone 4 mg 
tablet.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable home ventilator (E0466). 
 
You asked the Plan to pre-approve a portable home ventilator. You say that the requested device is medically 
necessary. The Plan denied your request. The Plan says the requested device does not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 
 
 
 
 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 portable home ventilator. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found you have chronic 
respiratory failure from chronic obstructive pulmonary disease. The provided primary source documentation 
does not contain sufficient detailed information in the medical record to justify the treatment selected. You 
could be treated with a BiPAP machine with AVAPS/IVAPS capability. The plan has indicated such a device 
is available. The provider has indicated that the Phillips Respironics recall precludes its use. However, this 
argument does not address the alternative source device. 
 
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 portable home ventilator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a portable home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G orthotic device (L8702). 
 
You asked the Plan to pre-approve the orthotic device. You say that the enrollee was referred by her physician 
for myoelectric orthotic restoration using the MyoPro Motion G. The Plan denied your request. The Plan says 
this brace is unproven and 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. The rules also say that experimental and investigational devices are not covered.  
 
We looked at this the file, and Medicare rules. There are not enough studies to show that the MyoPro orthotic 
improves the health of patients with your medical condition. Based on this information, we decided that 
Medicare rules for coverage of the orthotic device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the MyoPro Motion G orthotic device (L8702).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cochlear implant services. 
 
You asked the Plan to pre-approve cochlear implant services. You say that this procedure is medically 
necessary for your condition. The Plan denied your request. The Plan says the criteria to cover cochlear 
implants implantation have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that cochlear implantation may be covered when the 
device to be used is in accordance with Food and Drug Administration (FDA)-approved labeling 
 
We looked at the file and Medicare rules. In this case, the medical records do not indicate the specific cochlear 
implant that is to be used. Coverage cannot be provided before this information is obtained Based on this 
information, we decided that Medicare rules for coverage of cochlear implant services have not been met. 
Therefore, we decided that the Plan does not have to pre-approve cochlear implant services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that it is not reasonable or necessary to receive inpatient SNF level therapy 
for a member who is functioning at their physical baseline. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that you were not notified that your benefit 
period was exhausted. You also say you are not ready to be released because you are still unable to stand up, 
you have to be lifted to get into your chair. The Plan denied your request. The Plan says you have exhausted 
100 skilled nursing facility days for the current benefit period. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from December 23, 2021, 
through March 22, 2022. The Plan has covered 100 days of SNF care. 
 
 
 
 
 
 
 Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the overdenture (D5865), prefabricated abutment 
modification (D6056) and precision attachment (D6950). 
 
You asked the Plan to pre-approve the overdenture, prefabricated abutment modification and precision 
attachment. You say that you would like reconsideration because the ill fitting dentures you currently have are 
causing medical issues. The Plan denied your request. The Plan says the requested dental services are 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. 
 
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 
overdenture (D5865), prefabricated abutment modification (D6056) and precision attachment (D6950).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee needs SNF care. The Plan denied your 
request. The Plan says the enrollee does not meet the criteria for a SNF admission. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found that the enrollee does not have daily skilled 
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The 
enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on 
an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an ultrasound and a gynecology specialist 
office visit provided on August 10, 2020, and December 4, 2020. 
 
You asked the Plan to waive the copayments for an ultrasound and a specialist office visit. You say that this is 
an old bill. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 
copayment for diagnostic radiology services, including ultrasounds. The Plan contract also says that enrollees 
must pay a $40 copayment for a specialist office visit. 
 
 The record shows these claims were approved, and you have a cost sharing amount. You have been asked to 
pay a $100 copayment for each ultrasound on August 10, 2020, and December 4, 2020. An ultrasound falls 
within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. You have also 
been asked to pay a $40 copayment for each specialist office visit on August 10, 2020, and December 4, 2020. 
A specialist office visit falls within the Physician/Practitioner Services, Including Doctors Office Visits 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 copayments for an ultrasound and a gynecology specialist 
office visit provided on August 10, 2020, and December 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses (V2020, V2750, V2781) and routine eye exam 
(S0621) provided on November 1, 2021. 
 
You asked the Plan to pay for the routine vision services. You say that you feel you have been misled regarding 
your benefits and the eligibility of these services. The Plan denied your request. The Plan says the provider in 
this case is not part of the specified routine vision network. Your benefit only applies toward the purchase and 
fitting of eyeglasses and pair of lenses or contact lenses at a network optical provider. 
 
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 up to $100 when they are received from a provider in the specified 
routine vision network. 
 
We looked at the file and the Plan's rules. The provider in this case is not part of the Plan's specified vision 
vendor network. Based on this information, we decided that the Plan's rules for coverage of the routine vision 
services have not been met. Therefore, we decided that the Plan does not have to pay for the eyeglasses 
(V2020, V2750, V2781) and routine eye exam (S0621) provided on November 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging (MPI). 
 
You asked the Plan to pre-approve MPI. You say that the services are necessary. The Plan denied your request. 
The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that cardiovascular nuclear imaging is indicated under 
certain circumstances. 
 
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 MPI. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found there is no evidence provided that would 
support the need for radionuclide stress testing. In summary, there is insufficient documentation to support the 
medical necessity for the requested cardiac stress testing in your clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MPI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve myocardial perfusion imaging (MPI).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient laboratory services (87641, 
87640) provided on December 9, 2021. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 
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 $40 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
  You have been asked to pay a $40 copayment for laboratory services. Laboratory services falls within the 
Outpatient diagnostic tests and therapeutic services and supplies 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 copayment for outpatient laboratory services (87641, 87640) provided on December 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve An office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve An office visit. You say that you are asking for a specific OON provider. 
The Plan denied your request. The Plan says the provider is out-of-network and it was determined these 
services can be received in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the 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 
An office visit to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on October 12, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says these services are 
not separately payable. 
 
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 lab services provided on October 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontics (D6240) for tooth #'s 12, 29, 3, 7, and 9. 
 
You asked the Plan to pre-approve the pontics. You say that you have trouble chewing which prevents you 
from eating properly. The Plan denied your request. The Plan says bridges are covered to replace only 1 upper 
anterior tooth or only 2 adjacent lower anterior teeth. The Plan also says that the x-rays show that you are 
missing other teeth. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the pontics 
when the services are medically necessary and reasonable.  
 
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 pontics. Our reviewer says that 
there is no necessity for the requested pontics. Our physician reviewer found there are many missing teeth in 
both upper and lower arches which could be replaced more cost effectively with a removable appliance. Our 
reviewer found that the Plan also notes bridges may be considered only where there a patient is missing only 
one upper front tooth or only two lower front teeth. Our physician reviewer also found that there are posterior 
teeth that have been noted to be replaced in the current claim. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the pontics have not been met. Therefore, we decided that the Plan does not 
have to pre-approve pontics (D6240) for tooth #'s 12, 29, 3, 7, and 9.