Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry services provided on August 25, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for podiatry services. You say that it was not your responsibility to obtain 
authorization. The Plan denied your request. The Plan says the services were provided out-of-network and were 
not approved in advance. 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for podiatry services provided on August 25, 2021 by 
an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Alprazolam for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under Part B. 
 
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. Therefore, we decided that the Plan does not have to pre-approve Alprazolam for the enrollee.  
 
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Methotrexate for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered by the Plan. 
 
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. Therefore, we decided that the Plan does not have to pre-approve Methotrexate for the 
enrollee.  
 Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine PCR testing provided on December 1, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the testing was not 
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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that urine PCR amplification techniques raise considerable concerns regarding contamination from one 
specimen to another, creating the potential for false-positive results. The clinical interpretation of PCR results 
may also be challenging. Amplification of organisms representing latent infection or colonization cannot be 
distinguished from active, clinically significant infections. Additionally, PCR may amplify fragments of nucleic acids, representing dead microorganisms, thus further 
clouding the clinical interpretation. Finally, specificities, sensitivities, and positive and negative predictive 
values of PCR have not been reported in large groups of patients for many of the microorganisms. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the urine PCR testing provided on December 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam CT (D0367), diagnostic casts (D0470), 
unspecified preventive service (D1999), osseous surgery (D7950), implant placement (D6010), bone 
replacement graft (D7953), and interim partial denture (D5821) provided from October 15, 2021, to November 
22, 2021. 
 You asked the Plan to pay for the dental services. You say that your teeth were in too severe condition for 
normal extraction. You say that your dentist advised these services were necessary. You also say that if the 
services are not covered under your dental coverage, they should be covered under your medical coverage. The 
Plan denied your request. The Plan says the cone beam CT, diagnostic casts, unspecified preventive service, 
osseous surgery, implant placement, and bone replacement graft are not listed as covered services. The Plan 
also says that the interim denture is not valid. 
 
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, services you received are not among 
those covered under this benefit. Additionally, the services you are asking the Plan to pay for involve the care, 
treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These 
are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not 
have to pay for the cone beam CT (D0367), diagnostic casts (D0470), unspecified preventive service (D1999), 
osseous surgery (D7950), implant placement (D6010), bone replacement graft (D7953), and interim partial 
denture (D5821) provided from October 15, 2021, to November 22, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on November 8, 2021 and 
November 11, 2021 and psychotherapy services provided on November 17, 2021. 
 
You asked the Plan to pay for the psychotherapy services. You say that these services are covered according to 
the Plan information that you have. The Plan denied your request. The Plan says Outpatient Mental Health 
Care: Covered services include, Mental health services provided by a state-licensed psychiatrist or doctor, 
clinical psychologist, clinical social worker, clinical nurse specialist, nurse practitioner, physician assistant, or 
other Medicare-qualified mental health care professional as allowed under applicable state laws. 
 
The Plan must follow Medicare rules. Medicare rules say that a Mental Health Counselor and a Marriage 
Family Therapist is not eligible to participate in the Medicare program.  
 
We looked at the file and Medicare rules. The providers at issue in this case are a Mental Health Counselor and 
a Marriage Family Therapist. Medicare says that a Mental Health Counselor and a Marriage Family Therapist are not eligible to participate in the Medicare program. Therefore, we decided that the Plan does not have to 
pay for psychotherapy services provided on November 8, 2021 and November 11, 2021 and psychotherapy 
services provided on November 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the replacement of broken teeth, per tooth, (D5640) provided 
on December 15, 2021. 
 
You asked the Plan to pay for the dental service. You say that you have not used your dental benefits in 2 
years. You say that you have up to $500 in dental benefits. You also say that your services should be covered 
now. The Plan denied your request. The Plan says replace broken teeth is not listed as a covered dental service. 
 
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, replace broken teeth is not among 
those covered under this benefit. Additionally, the record shows that you are not enrolled in the optional supplemental dental coverage. Therefore, we decided that the Plan does not have to pay for the replacement of 
broken teeth, per tooth, (D5640) provided on December 15, 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 were told that the specific provider was in-
network. 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 laboratory services rendered on October 14, 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 were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
 
 We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on October 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 services are not medically necessary. Our physician reviewer found the enrollee has post-menopausal 
osteoporosis and has been taking Fosamax. She has not tried and failed the Plan's required drugs, an oral 
bisphosphonate and zoledronic acid. The records do not show that the required drugs would be contraindicated 
or less effective; therefore, the the Prolia is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Prolia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the walker, folding, wheeled, adjustable or fixed height 
(E0143) and sales tax (S9999) provided November 1, 2021. 
 
You asked the Plan to pay for the walker. You say that the equipment is required due to your medical need and 
your conditions that support its necessity. The Plan denied your request. The Plan says this provider is not 
certified for Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the walker, folding, wheeled, adjustable 
or fixed height (E0143) and sales tax (S9999) provided November 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be 
provided at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for a femur fracture and 
was transferred to skilled nursing then discharged home. There is ongoing weakness. The enrollees medical 
problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the patient has a need for physical and/or occupational therapy, there is 
no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that 
this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria 
for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection services provided to the enrollee on October 12, 
2021. 
 
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 the provider did not bill as required by Medicare coding regulations. 
 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 64494 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 the 
services have not been met. Therefore, we decided that the Plan does not have to pay for injection services 
provided to the enrollee on October 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive pharmacogenomic testing provided on 
August 24, 2021. 
 
You asked the Plan to pay for the comprehensive pharmacogenomic testing. You say that the medical records 
support the necessity of this testing. The Plan denied your request. The Plan says this was not billed with a 
single panel code as required and has an inappropriate POS code reported. 
 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. Based on this information, we decided that Medicare rules for 
coverage of the comprehensive pharmacogenomic testing have not been met. Specifically, this claim was billed 
with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. 
Therefore, we decided that the Plan does not have to pay for the comprehensive pharmacogenomic testing 
provided on August 24, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ER visits provided on January 3, 2022, 
and January 6, 2022. 
 
You asked the Plan to waive the copayment for the ER visits. You say that you feel you shouldn't have to pay 
because it was their negligence it wasnt fixed the first time. The Plan denied your request. The Plan says the 
copayment applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment for each emergency room visit. 
 
You have been asked to pay a total of $180 ($90 x 2 visits = $180). ER visits fall within the Emergency care 
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 the ER visits provided on 
January 3, 2022, and January 6, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient treatment provided on January 26, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient treatment. You say that you were told you did not need an 
authorization and you submitted the claim to get a not covered service denial. The Plan denied your request. 
The Plan says the rendering provider is an out-of-network provider and there was no referral from an in-
network provider or an approved authorization. Also, the service rendered was not urgent or emergent. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the outpatient treatment provided on January 26, 
2021, 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 two alveoloplasties in conjunction with extractions 
(D7310 x2) provided on November 22, 2021. 
 
You asked the Plan to pay for the alveoloplasties. You say that you believe this service should be covered 
because it is medical too. You also say that it had to be done for the enrollee to wear his bottom teeth. The Plan 
denied your request. The Plan says this service is not covered. 
 
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 the two 
alveoloplasties in conjunction with extractions (D7310 x2) provided on November 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF liquid biopsy provided on August 2, 2021. 
 
You asked the Plan to pay for the Tempus xF liquid biopsy. You say that this is medically necessary testing 
that should be covered. The Plan denied your request. The Plan says this testing was not billed with a single 
panel code as required and is reported with an inappropriate POS code. 
 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. Based on this information, we decided that Medicare rules for 
coverage of the Tempus xF liquid biopsy have not been met. Specifically, this claim was billed with the 
laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, 
we decided that the Plan does not have to pay for the Tempus xF liquid biopsy provided on August 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tub stool or bench (E0245). 
 
You asked the Plan to pre-approve a tub stool or bench. You say that the enrollee has to remove their oxygen to 
shower which causes difficulty breathing, lightheaded and dizziness. The Plan denied your request. The Plan 
says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a tub stool or bench (E0245).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat (E0244). 
 
You asked the Plan to pre-approve a raised toilet seat. You say that this is necessary to prevent injuries. The 
Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While a raised toilet seat may be appropriate for you, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat (E0244).