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

 
We decided that the Plan does not have to pre-approve Dalvance injections (J0875) 1500 mg every 2 weeks for 
8 months. 
 
 
You asked the Plan to pre-approve the injections. You say that at this point options for the enrollee's chronic 
suppression for recurrent Corynebacterium striatum infection related to left ventricular assist device are limited 
to dalbavancin and oritavancin. The Plan denied your request. The Plan says Dalvance has been approved for 4 
months. After the fourth month, updated medical records will be needed to support continued use. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 injections. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the review indicates that the enrollee has a recurrent deep driveline infection while on 
suppressive oral therapy and has developed significant intolerance to IV Vancomycin with only options left 
being Dalbavancin and Oritavancin. After review, the requested service was partially approved for four months 
in this unique and unfortunate situation where there are no other options left to treat this life-threatening infection (recurrent deep driveline infection/LVAD). The review has determined that the Plan's denial is 
medically justified on the basis that it is offering adequate care to meet the enrollee's medical needs by 
approving the Dalvance for only 4 months with 8 visits and the Plan is offering the standard of care for the 
treatment of the enrollee's 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 the injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Dalvance injections (J0875) 1500 mg every 2 weeks for 8 months.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99219 provided on February 1, 2022. 
 
You asked the Plan to pay for procedure code 99219. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan denied payment for code 99219 due to the use of an invalid modifier. 
However, the Plan failed to provide any claim that shows code 99219 was billed with any modifiers. The Plan 
has not provided any other rationale for their denial; therefore, we find that the Plan has not provided enough 
evidence to deny the claim for payment based on Medicare guidelines. Therefore, we decided that the Plan has 
to pay for procedure code 99219 provided on February 1, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the glasses provided on May 4, 2022. 
 
You asked the Plan to pay more for the glasses. The Plan denied your request. The Plan says the benefit 
maximum has been met. 
 Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers up to a total of $250 every 2 years for eyeglasses. 
 
We looked at the file and the Plan's rules. The record shows that the Plan paid $250 for these glasses purchased 
on May 4, 2022, and your eyeglasses allowance has been exhausted. Based on this information, we decided that 
the Plan's rules for coverage of the glasses have not been met. Therefore, we decided that the Plan does not 
have to pay more for the glasses provided on May 4, 2022.
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 September 8, 2021. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that it was 
communicated to you that this ambulance invoice is covered under your current healthcare insurance policy. 
The Plan denied your request. The Plan says the service in question is not covered under your contract under 
any normal circumstances. 
 
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 September 8, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
The record shows that you signed the refusal of treatment/transportation, acknowledging you refused treatment 
and transport. Therefore, we decided that the Plan does not have to pay for the ambulance response and 
treatment with no transport (A0998) provided on September 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the expandable controller and related accessories. 
 
You asked the Plan to pre-approve the expandable controller and related accessories. You say that the 
expandable controller and accessories are medically necessary. The Plan denied your request. The Plan says the 
criteria for coverage 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 the expandable controller and related 
accessories. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has a neurologic disorder with functional 
deficits. Criteria for a power wheelchair are met. However, the requested electrical accessories are not 
medically necessary as the enrollee does have use of the upper extremity and can operate and control the power 
options using the switches that are included in the basic wheelchair. Therefore, the requested expandable 
controller and related accessories exceed their need and are not medically reasonable and 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 expandable controller and related accessories have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the expandable controller and related accessories.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen and 
pelvis (74176). 
 
You asked the Plan to pre-approve a CT scan of the abdomen and pelvis. You say that the requested service is 
medically necessary. The Plan denied your request. The Plan says the service at issue is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 CT scan of the abdomen and pelvis. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the provided 
records do not document symptoms specific to the abdominal or pelvic area and the records do not document 
any abnormal physical examination findings with regard to the abdomen or pelvis. Supplied laboratory studies 
show no acute abnormalities referable to the abdomen or pelvis.  
 
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 CT scan of the abdomen and pelvis have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen and pelvis 
(74176).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a walker provided on February 5, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for a walker. You say that you would like to request reconsideration for payment. 
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 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 a walker provided on February 5, 2022, by an out-
of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture visits provided on September 20, 2021, to 
September 27, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for acupuncture visits. You say that you would like to appeal the denial of the claim. 
The Plan denied your request. The Plan says the provider is out-of-network and authorization is required prior 
to an out-of-network visit. 
 
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 acupuncture visits provided on September 20, 
2021, to September 27, 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 determination of refractive state (92015) provided on 
April 27, 2022. 
 
You asked the Plan to pay for the determination of refractive state. You say that you were told you had to pay 
for this service because the machine printed it, even though you did not want it. The Plan denied your request. 
The Plan says this service is not covered. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. 
 
We looked at the file and the Plan's rules. The contract says that Original Medicare does not cover routine eye 
exams (eye refractions). The record shows that you received a medical eye exam. Based on this information, 
we decided that the Plan's rules for coverage of the determination of refractive state have not been met. 
Therefore, we decided that the Plan does not have to pay for the determination of refractive state (92015) 
provided on April 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the targeted genomic sequence analysis (0037U) provided on 
January 31, 2022. 
 
You asked the Plan to pay for the targeted genomic sequence analysis (0037U). You say that the test meets the 
requirements of the NCD and has been determined by CMS to be reasonable and necessary. You say that the 
original decision should be reversed, and the claim covered. The Plan denied your request. The Plan says the 
claim was billed with a date of service inconsistent with Medicare rules governing laboratory services. 
 
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 0037U is targeted genomic sequence analysis, solid organ 
neoplasm, DNA analysis of 324 genes, interrogation for sequence variants, gene copy number amplifications, 
gene rearrangements, microsatellite instability and tumor mutational burden. 
 
We find that CPT code 0037U is not supported in the medical record. Specifically, the incorrect date of service 
was billed. Based on this information, we decided that Medicare rules for coverage of the targeted genomic 
sequence analysis (0037U) have not been met. Therefore, we decided that the Plan does not have to pay for the 
targeted genomic sequence analysis (0037U) provided on January 31, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve home health services. You say that the requested services are a medical 
necessity for you. The Plan denied your request. The Plan says rules for coverage for OON services have not 
been met. 
 
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 
home health services to be provided by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that you continue to receive acute care services, and these have not been denied. The 
medical record does not indicate that you require services that are not currently being received but that would 
be available at the LTACH facility. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97010 billed for date of service  
November 11, 2021. 
 
You asked the Plan to pay for procedure code 97010. The Plan denied your request. The Plan says procedure 
code 97010 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code 97010 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 97010 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 97010 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 97010 billed for date of service November 11, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99309) 
rendered by the out-of-network (OON) provider on November 26, 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 a prior valid 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 have a valid authorization on file. 
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 subsequent nursing facility care, per day (99309) rendered by the out-of-network 
(OON) provider on November 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient admission on June 6, 2022. 
 
You asked the Plan to waive the copayment for an inpatient admission. You say that you did not receive any 
inpatient care but only treatment in the emergency department. The Plan denied your request. The Plan says the 
correct copayment was applied. 
 
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 $325 
copayment for each admission for a medically necessary inpatient stay.  
 
 
  In this case, the case record indicates that you were admitted for inpatient care following an emergency 
department visit. You declined care and left the hospital against medical advice. Your decision to leave does 
not address the medical necessity of the admission. You have been asked to pay a $325 copayment for an 
inpatient admission. An inpatient admission falls within the Inpatient Hospital 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 an inpatient admission on June 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral evaluation (D0120) and prophylaxis - 
adult (D1110) provided on March 21, 2022. 
 
You asked the Plan to pay more for the dental services. You say that the provider is listed as in-network. The 
Plan denied your request. The Plan says you are responsible for any charged amount above the Plans cost-
sharing amount when your services are received from an out-of-network provider. 
 
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for periodic oral evaluation (D0120) and 
prophylaxis - adult (D1110) provided on March 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for topical application of fluoride varnish (D1206) provided on 
May 10, 2022. 
 
You asked the Plan to pay for the fluoride varnish. You say that you are susceptible to periodontal gum disease 
which is why you were delighted to hear about this procedure. The Plan denied your request. The Plan says the 
service provided is not a covered benefit under your dental plan.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for topical 
application of fluoride varnish (D1206) provided on May 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87640, 87653, and 87798 billed for 
date of service January 11, 2022. 
 
You asked the Plan to pay for procedure codes 87481, 87640, 87653, and 87798. You say that you would like 
the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says payment for codes 
87481, 87640, 87653, and 87798 are bundled into payment for codes 87801 and 87150. 
 
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 codes 
87481, 87640, 87653, and 87798 are column II codes to column I codes 87801 and 87150. 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 procedure codes 
87481, 87640, 87653, and 87798 billed for date of service January 11, 2022.