Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient hospital care provided on June 9 to June 11, 
2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient hospital care at issue was 
a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for 
the care at issue have not been met. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the record did not show that at the time of inpatient admission the admitting 
physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for acute inpatient hospital care provided on June 9 to June 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the osteogenesis stimulator (E0748) 
provided on April 5, 2021. 
 
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to 
the item 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 50% 
coinsurance for Medicare-covered durable medical equipment and related supplies rendered by an out-of-
network provider.  
 
 
 
 
 You have been asked to pay $2,264.52 (Plan allowed amount of $4,529.04 x 50% coinsurance) for the durable 
medical equipment rendered by an out-of-network provider. 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 the osteogenesis stimulator (E0748) provided on April 5, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an elective esophagogastroduodenoscopy (EGD) 
(43239, 43235) to be performed at a hospital. 
 
You asked the Plan to pre-approve an EGD to be performed at a hospital. You say that you would like an EGD 
to be covered in the outpatient hospital setting. The Plan denied your request. The Plan says there are 
ambulatory surgery centers available for the enrollee to have the services performed. There is no 
documentation of medical conditions that would require a hospital setting for this procedure. 
 
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 an EGD to be performed at a hospital. 
Our reviewer says that the requested place of service is not considered medically reasonable and necessary in 
this case. Our physician reviewer found that based on the medical records provided there is no documentation 
of any underlying medical conditions or unstable patient factors which would necessitate performing the 
esophagogastroduodenoscopy at a hospital as opposed to an ambulatory surgery center. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an EGD to be performed at a hospital have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an elective esophagogastroduodenoscopy (EGD) (43239, 43235) to 
be performed at a hospital.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the WATS 3D brush biopsy rendered on August 3, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that modifier -26 is required for separate payment of 
the PC of testing services when furnished in a different payment locality than the TC. 
 
We looked at the file and Medicare rules. The file shows that procedure code 88305 (surgical pathology) was 
not billed with the required -26 modifier to allow for separate PC payment. Therefore, we decided that the Plan does not have to pay for the WATS 3D brush biopsy rendered on August 3, 
2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of pegfilgrastim. 
 
You asked the Plan to pre-approve pegfilgrastim. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the denial of authorization for this drug is correct, because there is no 
documentation as to why the enrollee cannot try eribulin without pegfilgrastim. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 pegfilgrastim. Our reviewer says that 
the enrollee does not meet the Medicare criteria for the requested use of pegfilgrastim. Our physician reviewer 
found the enrollee is being prescribed this drug for prophylaxis of febrile neutropenia in the setting of eribulin 
treatment of breast cancer. This chemotherapy regimen does not have a clinically significant incidence of 
febrile neutropenia. The Food & Drug Administration (FDA) has not stated that pegfilgrastim is indicated for 
the enrollee's condition. This requested use is not supported by one of the major drug compendia or by clinical 
research appearing in a Medicare-approved medical journal. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of pegfilgrastim have not been met. Therefore, we decided that the Plan does not 
have to pre-approve use of pegfilgrastim.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (81529) rendered by the out-of-
network (OON) provider on December 3, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the laboratory service (81529) rendered by the out-of-network (OON) provider on 
December 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Fluid Flow injections provided on September 10, 2021. 
 
You asked the Plan to pay for the Fluid Flow injections. You say that this was a medically necessary treatment. 
The Plan denied your request. The Plan says there is no sufficient evidence to support the medical necessity of 
this treatment. 
 
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 Fluid Flow injections. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found Fluid Flow injections remain experimental for use in joint pain patients.  
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 Fluid Flow injections have not been met. Therefore, we decided that the 
Plan does not have to pay for the Fluid Flow injections provided on September 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on May 9, 2021. 
 
You asked the Plan to pay for the services provided. You say that you were compliant with regulations for 
billing. The Plan denied your request. The Plan says the billed code cannot be verified. 
 
 The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. The records show that the claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. 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 the lab testing services provided on May 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the WATS 3D Biopsy provided on August 6, 2021. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says your request does not meet Medicare rules because a review of the medical literature and clinical 
practice guidelines does not support the clinical utility of this testing, including computer-assisted 
immunohistochemistry, to predict cancer. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the record indicates that the enrollee has esophagitis. There is insufficient literature to support 
the safety efficacy of the requested service for the enrollee's condition. The American Society of Gastrointestinal Endoscopy has given the requested service a conditional recommendation for the noted 
diagnosis with low level evidence, insufficient to establish safety and efficacy, as defined by Medicare rules. 
The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, 
of the requested service. The elements of the coverage criteria are not satisfied. The requested service is not 
recommended. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for the WATS 3D Biopsy provided on August 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you an additional amount for hearing aids provided on 
September 27, 2021. 
 
You asked the Plan to reimburse you an additional amount for hearing aids. The Plan denied your request. The 
Plan says you have been reimbursed $150 as per your hearing benefits. 
 
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.  
 
We looked at the file and the Plan's rules. The file shows that the Plan has paid the benefit amount of $150, and 
you are responsible for the balance. Therefore, we decided that the Plan does not have to reimburse you an 
additional amount for hearing aids provided on September 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab tests provided on July 14, 2021. 
 
You asked the Plan to pay for the services provided. You say that there is no agreement which indicates the 
codes are included in the dialysis rate. The Plan denied your request. The Plan says the lab tests are the 
responsibility of the dialysis center. 
 
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 tests provided on July 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on October 25, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered.  
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on October 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyeglass lens enhancements: Lens, polycarbonate or equal, 
U -V Lens, Anti -Reflective Coating and Progressive Lens provided on November 17, 2021. 
 
You asked the Plan to pay for eyeglass lens enhancements. The Plan denied your request. The Plan says lens 
enhancements are excluded from coverage. 
 Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
We looked at the file and the Plan's rules. The file shows that the Plan does not cover lens enhancements. The 
Plan covers single vision, lined bifocal, lined trifocal, and lenticular and frames. Therefore, we decided that the 
Plan does not have to pay for eyeglass lens enhancements: Lens, polycarbonate or equal, U -V Lens, Anti -
Reflective Coating and Progressive Lens provided on November 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laboratory services (unlisted chemistry procedure). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there was limited clinical information submitted with this request. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is no documentation that the laboratory services Current Procedural Terminology (CPT) code 
84999 (unlisted chemistry procedure) at issue in this case meet Medicare criteria for medically reasonable and 
necessary. The provided medical records do not document an order for the requested service or document 
necessity of the requested service.  
 
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 pre-approve laboratory services (unlisted chemistry procedure).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office services (CPT code 99213) to be provided by 
a non-contracted PCP. 
 
You asked the Plan to pre-approve the office services. You say that you need a doctor that can actually help 
you and you are losing money. The Plan denied your request. The Plan says this provider is not a contracting 
primary care provider with the plan. 
 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. Based on this information, we decided that Medicare rules for 
coverage of the office services have not been met. This provider is chiropractic doctor. This provider is not a 
contracting primary care provider with the plan. Your 2022 EOC states, "Generally, Internal Medicine, General 
Medicine, Geriatrician, or Family Practitioners act as PCPs. A nurse practitioner or physician's assistant may 
also be a PCP." Therefore, we decided that the Plan does not have to pre-approve the office services (CPT code 
99213) to be provided by a non-contracted PCP.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit with a tertiary neurologist. 
 
You asked the Plan to pre-approve an office visit with a tertiary neurologist. You say that the enrollee does not 
require the requested level of care. The Plan denied your request. The Plan says this is medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an office visit with a tertiary 
neurologist. Our reviewer says that the requested services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the submitted clinical information is not sufficient to 
support that evaluation with a tertiary neurologist is medically reasonable and necessary for the enrollee in this 
case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an office visit with a tertiary neurologist have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an office visit with a tertiary neurologist.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on August 17, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 27335 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 27335 (knee arthrotomy with with synovectomy) and 
27447 (total knee arthroplasty). Code 27335 is a column II code with a modifier indicator of 1 when billed with 
column I code 27447. Code 27335 was not billed with an appropriate modifier to allow for separate payment. 
The -59 modifier is not supported as a separate and distinct procedural service. Therefore, we decided that the 
Plan does not have to pay for the surgical services rendered on August 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (CPT code 81551) provided on 
September 2, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that the services should be covered, and the 
denied claim should be reprocessed for payment. The Plan denied your request. The Plan says they need the 
primary insurance carriers Explanation of Benefits (EOB). 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways.  First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the 
provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for 
reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has The Plan 
needs the primary insurance carriers Explanation of Benefits (EOB). The EOB that was sent is a Medicare 
EOB example and the service date does not match the date of service the services were rendered. As the 
secondary insurer, the Plan cannot be held responsible for the laboratory service until the primary insurer has 
denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the laboratory 
service (CPT code 81551) provided on September 2, 2021.