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

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on May 3, 
2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you were not at the hospital at 
all, nor an out-patient, and in any way serviced by or in an operating room. You say you are requesting to 
refund the excessive monies paid to them for the insurance coverage. The Plan denied your request. The Plan 
says you have been charged the correct copayment 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 $275 
copayment for each Medicare-covered outpatient hospital visit.  
 
 
 
 
 
 You have been asked to pay a $275 copayment for outpatient surgery. The outpatient surgery falls within the 
Outpatient Surgery, Including 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 outpatient surgery provided 
on May 3, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vertiflex Superion interspinous device at L3-4 and L4-5 
(22869, 22870). 
 
You asked the Plan to pre-approve Vertiflex Superion interspinous device at L3-4 and L4-5. You say that the 
requested service is medically necessary. The Plan denied your request. The Plan says the service is not 
medically necessary as it efficacy has not been established. 
 
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 Vertiflex Superion interspinous device 
at L3-4 and L4-5. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found current evidence based medical guideline and peer 
reviewed literature do not fully support the spinal decompression device procedure over lumbar laminectomy. 
There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for 
this enrollees medical condition. There is no compelling rationale presented or extenuating circumstances 
noted to support the medical necessity of this request as an exception. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vertiflex Superion interspinous device at L3-4 and L4-5 have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Vertiflex Superion interspinous device at L3-
4 and L4-5 (22869, 22870).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on July 1, 2020. 
 
You asked the Plan to pay for the medical services. You say that these services were necessary and should be 
paid. The Plan denied your request. The Plan says you did not timely file this claim. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the medical services was not filed until May 16, 2022. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for medical services provided on July 1, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 22045 billed for date of service March 22, 
2022. 
 
You asked the Plan to pay for procedure code 22045. You say that the records show the necessity of this 
service. The Plan denied your request. The Plan says code 22045 is not supported in the medical record. The 
documentation states that a biopsy of the coccyx was performed, which is not considered a deep bone. There is 
a more appropriate code available. 
 
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, the CPT Code Manual definition of code 22045 is Biopsy, bone, open; deep (eg, humeral shaft, 
ischium, femoral shaft). 
 
We asked our coder 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 procedure code 22045. Our reviewer says that procedure 
code 22045 is not supported in the medical record. Our reviewer found the procedure report describes 
procedures performed on coccyx. Code 22045 represents deep bone (e.g., humeral shaft, ischium, femoral shaft).  In this case, there is a more appropriate code to report for service provided.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 22045 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 22045 billed for date of service March 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pain management, analysis of 11 endogenous analytes, 
(0117U) provided on January 26, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that this is a Medicare allowed code. The Plan 
denied your request. The Plan says there is no order from the member's primary care physician (PCP) or 
attending physician for the services. 
 
The Plan must follow Medicare rules. Medicare rules say that tests not ordered by the physician who is treating 
the beneficiary are not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory service have not been met. Specifically, the file does not show that the service in this 
case was ordered by enrollee's treating physician. Therefore, we decided that the Plan does not have to pay for 
the pain management, analysis of 11 endogenous analytes, (0117U) provided on January 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says that records do not show an arterial blood gas to support respiratory failure and a 
ventilator is not to be used in CPAP or bi-level PAP mode only as other machines are capable of providing this 
type of treatment. 
 
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 home ventilator. Our reviewer says 
that a home ventilator is not medically reasonable and necessary. You have a diagnosis of COPD, but there are 
no pulmonary function tests to confirm and to assess severity. Arterial blood gas results are provided from two 
occasions in August 2022, that show normal PaCO2. Our physician reviewer found that your condition does not meet Medicare criteria for a home ventilator. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF is not medically 
necessary. 
 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found daily skilled services are not required to establish a maintenance program or to 
prevent deterioration of your condition. 
 
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) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 19, 2021 billed with 
codes 81206, 81235, 81210, 81275, 81276, 81292, 81295, 81298, 81311, 81317, 81321, 81301, 81309, and 
81191. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says the testing 
was billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
October 19, 2021 billed with codes 81206, 81235, 81210, 81275, 81276, 81292, 81295, 81298, 81311, 81317, 
81321, 81301, 81309, and 81191.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to lower the copayment for a computerized tomography (CT) scan 
provided on March 3, 2022. 
 
You asked the Plan to lower the copayment for the CT scan. You say that you thought the copayment would be 
lower for the service that was rendered. The Plan denied your request. The Plan says the proper copayment was 
applied for the service that was rendered. 
 
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 $250 
copayment for Medicare-covered diagnostic radiology services that are not ultrasounds. You will only pay one 
copayment per day even if multiple diagnostic radiology services are performed. The total amount allowed for 
the CT scan was $196.88 which is less than the copayment amount of $250. Therefore, only $196.88 was 
charged as the copayment amount. 
 
  You have been asked to pay a $196.88 copayment for the CT scan. The CT scan 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 lower 
the copayment for a computerized tomography (CT) scan provided on March 3, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FoundationOneCDx (F1CDx) testing provided on February 25, 
2022. 
 
You asked the Plan to pay for the F1CDx testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says that the unique test identifier requirement is missing. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, such as the F1CDx panel, when provided for an FDA-approved indication. 
 
We reviewed the LCD cited by the Plan but find that it is not applicable to an FDA-approved test, as these are 
covered via the NCD cited in the Medicare rules section. An LCD cannot limit coverage allowed by an NCD, per 
the Medicare hierarchy of authority. In addition, the LCD used by the Plan is not valid for the Providers head 
quarter billing state of Pennsylvania. As such, we disregarded the LCD cited by the Plan. 
 
Medicare rules say that Medicare nationally covers FDA-approved NGS testing, such as the F1CDx panel, when 
provided for an FDA-approved indication. Therefore, we decided that the Plan has to pay for the 
FoundationOneCDx (F1CDx) testing provided on February 25, 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on March 14, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you were 
able to be stabilized so you did not need to be transported to the hospital. The Plan denied your request. The 
Plan says this service is not covered because you were not transported by the ambulance. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 14, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on March 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) guided adaptive 
radiotherapy services. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says there is 
no high-level evidence to support the 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 requested services. Our physician 
reviewer found the MRI based systems allow for adaptive planning which entails replanning the treatment 
before each treatment to account for anatomy at that given moment. There are non-MRI based systems that 
allow for replanning based on cone beam CT. There are no studies showing that adaptive planning or MRI-
based stereotactic body radiation therapy (SBRT) are necessary over standard SBRT. Without data, consensus 
guidelines or other sources demonstrating the need of MRI-based treatment (or adaptive planning) is 
unfavorable. Studies have shown SBRT to be safe and effective for pancreatic cancer. It does not appear that 
SBRT with the FDA-approved MRI platforms are necessarily superior to standard SBRT. 
 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve magnetic resonance imaging (MRI) guided adaptive radiotherapy services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2751) for tooth #31. 
 
You asked the Plan to pre-approve the crown. You say that the size is not suitable, and you cannot eat properly. 
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 June 15, 2022. Therefore, 
we decided that the Plan does not have to pre-approve a crown (D2751) for tooth #31.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Aurora Zip device. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that requested unproven and not medically necessary procedures are 
not covered by Medicare due to insufficient evidence of efficacy. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The Aurora zip 
device is experimental. More research is needed to show safety and efficacy. Our physician reviewer found that 
your condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Aurora Zip device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator for the enrollee. 
 
You asked the Plan to pre-approve a portable ventilator. You say that this is medically necessary. The Plan 
denied your request. The Plan says that the request for a home mechanical ventilator set in AVAPS mode with 
Auto-EPAP (AE) that could be delivered by BiPAP is not covered. 
 
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 ventilator. Our reviewer says 
that a portable ventilator is not medically reasonable and necessary. This patient was recently hospitalized with 
pneumonia, and has obesity-hypoventilation syndrome, with CO2 retention. He also has pulmonary 
hypertension. There is no diagnosis of COPD, thoracic restrictive disease, or neuromuscular disease. Medicare 
does not cover a home ventilator when used as BiPAP.  There is no documentation of failure of BiPAP as an outpatient. Our physician reviewer found that the 
enrollee's condition does not meet Medicare criteria for a portable ventilator. 
 
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 ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110). 
 
You asked the Plan to pre-approve a complete maxillary denture. You say that you were unable to use the last 
denture because it was too big. 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 25, 2020. 
Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110).  
 
Your complaint about the doctor being rude is not a valid appeal for medical coverage. This part of your 
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision 
about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain crown (D2750) for teeth #14 and #31 
 
You asked the Plan to pre-approve the porcelain crown. You say that the services should be covered as your 
previous crown is broken and you are having trouble chewing. The Plan denied your request. The Plan says the 
services denied correctly as the enrollees x-rays show crowns present on these teeth already and no 
radiographic evidence of decay or other issues that would necessitate a new crown. These teeth do not meet 
clinical requirements for a crown benefit. 
 
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. The Plan covers the porcelain 
crown 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 porcelain crown. Our physician 
reviewer found there is no statement from the provider as to a need for replacement of the crowns or addressing 
the pain in tooth #14.  It is noted that pain on chewing is not usually a symptom of a damaged crown but of 
endodontic involvement.  If endodontic treatment is required, the treatment can be rendered through the 
existing crown.  Given there is no apparent defect of the existing crowns that are being submitted for 
replacement, there is no finding of medical necessity for a replacement crown on teeth #14 and #31. 
 
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 porcelain crown have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a porcelain crown (D2750) for teeth #14 and #31.