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

 
We decided that the Plan does not have to pay for the definitive drug testing (G0483) provided on August 21, 
2020. 
 
You asked the Plan to pay for the drug testing. The Plan denied your request. The Plan says this testing is 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 drug testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that definitive drug testing is only appropriate to followup on an unexpected screening urine drug test 
which was not provided and presumed to not have been performed. The broad definitive testing of drugs was 
unnecessary and would not have led to improved care for this enrollee. Therefore, this request for definitive 
drug testing will be considered not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not 
have to pay for the definitive drug testing (G0483) provided on August 21, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services (99282) rendered 
on June 24, 2021. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you cut your thumb, 
called your provider and the provider said there were no appointments, so you would have to go to the 
emergency room. You also say you went to the emergency room and now have a bill. The Plan denied your 
request. The Plan says you were 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 $90 
copayment for each covered emergency room visit.  
 
 You have been asked to pay a $90 copayment for emergency room services. 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 emergency room services (99282) rendered on June 24, 2021.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for one intraoral x-ray and two extractions. We decided that the Plan does 
not have to pay for the limited oral evaluation, additional intraoral x-ray, and additional extraction.  
You asked the Plan to pay for the limited oral evaluation, intraoral x-rays, and extractions. You say that your 
dentist was informed the services would be covered and partially paid as an out-of-network dentist. You say 
that the benefits do not state that a dentist is required to be opted into Medicare and the claim should be paid 
out-of-network. The Plan says that payment cannot be issued for services from a provider that has opted out of 
Medicare. 
 
We decided that the Plan has to pay for one intraoral x-ray and two extractions.  
 
The billing provider and rendering provider on the claim are different. There is no documentation supporting 
that the rendering provider has opted out of Medicare. The Evidence of Coverage clearly states that one 
intraoral x-ray and two extractions are covered per calendar year from an out-of-network provider. Therefore, 
we decided that the Plan has to pay for one intraoral x-ray and two extractions according to your out-of-
network benefits.  
 
We also decided that the Plan does not have to pay for the limited oral evaluation, additional intraoral x-
ray, and additional extraction. 
 
The Evidence of Coverage clearly states that only one intraoral x-ray and two extractions are covered per 
calendar year. The limited oral evaluation is not listed as a covered benefit. Therefore, we decided that the Plan 
does not have to pay for the limited oral evaluation, additional intraoral x-ray, and additional extraction. 
 
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual wellness visit provided on January 21, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the annual wellness visit. You say that the service was medically necessary. The 
Plan denied your request. The Plan says no prior authorization was obtained. 
 
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 did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the annual wellness visit provided on January 21, 2021, by an 
out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the carpal tunnel surgery. 
 
You asked the Plan to pre-approve the carpal tunnel surgery. You say that you would like reconsideration 
because the requested procedure is medically necessary. The Plan denied your request. The Plan says the 
member does not have any signs of carpal tunnel and this procedure is being ordered to prevent symptoms of 
carpal tunnel. 
 
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 carpal tunnel surgery. Our reviewer 
says that detailed documentation is not evident regarding the medical necessity of the requested prophylactic 
carpal tunnel release that is being requested. The claimant has no signs and/or symptoms of carpal tunnel on 
exam or noted diagnostic testing to support a diagnosis of carpal tunnel syndrome. It is noted this would be 
prophylactic; however, there is limited published, large-scale, long-term peer-reviewed literature that shows 
that carpal tunnel syndrome is a significant post-operative complication from a proximal row carpectomy. Nor 
do the studies support undergoing this procedure without clinical indications to do so.  
  
Our physician reviewer found 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 the carpal tunnel surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the carpal tunnel surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal scaling and root planing (D4341), provided 
on April 15, 2021, and May 25, 2021. 
 
You asked the Plan to pay for the periodontal scaling and root planing. You say that the service should be 
covered. The Plan denied your request. The Plan says this is not a covered service. 
 
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. 
 
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. Specifically, the service is not listed in the Plan's benefit chart. 
Therefore, we decided that the Plan does not have to pay for the periodontal scaling and root planing (D4341), 
provided on April 15, 2021, and May 25, 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. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
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. 
 Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the documentation does support a need for physical and/or occupational 
therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 
 
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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a tooth extraction (D7140), a surgical placement (D6010), an 
implant/abutment fixed denture (D6118), and a prefabricated abutment (D6056) provided by an out-of-network 
provider on June 29, 2021. 
 
You asked the Plan to pay for a tooth extraction, a surgical placement, an implant/abutment fixed denture, and 
a prefabricated abutment. You say that you needed to have extractions in order to received dental implants. The 
Plan denied your request. The Plan says prior authorization was not obtained for an out-of-network dentist to 
provide these services. 
 
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. 
 
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 a tooth 
extraction (D7140), a surgical placement (D6010), an implant/abutment fixed denture (D6118), and a 
prefabricated abutment (D6056) provided by an out-of-network provider on June 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on November 30, 2020, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the home visit. You say that you are asking for payment to be made to the 
provider. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
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 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 a home visit provided on November 30, 2020, by 
an out-of-network (OON) provider.  
 Please note that this decision is only regarding date of service November 30, 2020. Please contact the Plan 
regarding appeals for any other dates of service. 
 
Your complaint about the unsafe discharge 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: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve an arterial doppler extremity study for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is no documentation of progressive symptoms since the last imaging on 
October 7, 2019. 
 
The Plan must follow Medicare rules. Medicare rules say that non-invasive vascular studies are considered 
medically necessary if the ordering physician has reasonable expectation that their outcomes will potentially 
impact the clinical management of the patient.  
 
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 considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has  significant lower extremity arterial occlusive disease bilaterally.  He has evidence of 
bilateral femoral popliteal artery occlusions. Ankle brachial indexes (ABIs) in October 2019 were 
approximately 0.6 bilaterally. As the enrollee at the time was not having evidence of limb threat and was 
otherwise doing well, the plan was for follow-up in two years with repeat doppler study or sooner if needed. 
Surveillance including obtaining an arterial doppler study in one or two years is reasonable and medically 
necessary as it would help detect progression of disease including progression to limb threatening ischemia. As 
symptoms can often be multifactorial, they can often not be reliable. A significant change from the previous 
ABI would change management in that it would alter the approach to the enrollee, the nature of questioning, 
and could potentially identify imminent limb threat. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve an arterial doppler extremity study for the enrollee.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377) and harness (E2313) 
for a power wheelchair. 
 
You asked the Plan to pre-approve an expandable controller and harness. You say that the requested items are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the 
requested items have not been met. 
 
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 expandable controller and harness. 
Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that there is no documentation that meets Medicare coverage criteria for the 
requested items. The approved Group 3 power wheelchair in this case does not possess the power options, 
actuator, or specialty controller which would justify the inclusion of the requested expandable controller and 
harness. 
 
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 expandable controller and harness have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an expandable controller (E2377) and harness (E2313) for a power 
wheelchair.
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. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory work provided on June 9, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the laboratory work. You say that the service was medically necessary. The Plan 
denied your request. The Plan says no prior authorization was obtained. 
 
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 did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
record shows CPT code 36415 was billed which means the provider had the opportunity to confirm insurance 
coverage and authorization. 
 
Therefore, we decided that the Plan does not have to pay for the laboratory work provided on June 9, 2021, by 
an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head or brain 
(70540) provided on June 29, 2021. 
 
You asked the Plan to pay for the CT scan services. You say that you would like this claim reprocessed based 
on the medical documentation. The Plan denied your request. The Plan says this claim was not billed with an 
appropriate modifier. 
 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, we have confirmed that code 70540 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the computed tomography (CT) scan of the head or brain (70540) 
provided on June 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an eye exam provided on November 19, 
2019. 
 
You asked the Plan to waive the copayment for an eye exam. You say that you disagree with the denied 
charges and should not be held responsible. The Plan denied your request. The Plan says the claims were 
processed correctly and you are being charged the correct 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 $35 
copayment for specialist visits. 
 
The medical records show that you had an eye exam provided by an ophthalmologist on November 19, 2019. 
Therefore, you are responsible to pay the $35 copayment.   
 
You have been asked to pay a $35 copayment for an eye exam. An eye exam falls within the 
physician/practitioner services, including doctor?s 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 copayment for an eye exam provided on November 19, 2019.