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

 
We decided that the Plan does not have to pre-approve removal of a toenail and trimming of toenails. 
 
You asked the Plan to pre-approve removal of a toenail and trimming of toenails. You say that removal of a 
toenail and trimming of toenails is medically necessary. The Plan denied your request. The Plan says the 
enrollee does not have evidence of mycosis. 
 
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 removal of a toenail and trimming of 
toenails. Our reviewer says that removal of a toenail and trimming of toenails are not considered medically 
reasonable and necessary in this case. Our physician reviewer found that the medical documentation does not 
advise that this enrollee has thick, mycotic, or dystrophic toenails which are tender. The only medical 
information concerning the enrollees feet include the fact that the enrollee has bunion deformities and a 
plantar wart left side. Medicare advises that they cover procedures that are reasonable and necessary for the 
treatment of an illness or injury or to improve the functioning of a malformed body member. These procedures 
must be safe and effective and appropriate for the diagnosis. The medical documentation does not support that 
this enrollee has a diagnosis or physical findings that would allow for removal of toenail and debridement of toenail. Therefore, it is my opinion that the requested toenail removal and trimming of toenails at issue in this 
case is not medically reasonable or 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 removal of a toenail and trimming of toenails have not been met. Therefore, we 
decided that the Plan does not have to pre-approve removal of a toenail and trimming of toenails.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on February 18, 2021. 
 
You asked the Plan to pay for chiropractic services. The Plan denied your request. The Plan says non-emergent, 
non-urgent services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for chiropractic services provided on February 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the technical component (TC) of the intraoperative 
neuromonitoring (IONM) services and related supplies provided on November 5, 2021. 
 
You asked the Plan to pay for the supplies and TC of the IONM services. You say that you have provided 
evidence that all supplies are owned by you and not the hospital and that no other provider can be reimbursed 
for these services. The Plan denied your request. The Plan says this is included in facility payment. 
 
The Plan must follow Medicare rules. Medicare rules say that all items and non-physician services furnished to 
inpatients must be furnished directly by the hospital or billed through the hospital under arrangements.  
 
We looked at the file and Medicare rules. The enrollee underwent inpatient surgery. The TC of diagnostic 
services comprises items and non-physician services. This can only be paid to the facility and must be provided 
under arrangement to ancillary providers. Based on this information, we decided that Medicare rules for 
coverage of the supplies and TC of the IONM services have not been met. Therefore, we decided that the Plan does not have to pay for the technical component (TC) of the intraoperative neuromonitoring (IONM) services 
and related supplies provided on November 5, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care services provided on December 
28, 2021, to December 30, 2021. 
 
You asked the Plan to pay for the subsequent hospital care services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services billed are not payable. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the subsequent hospital care services provided on December 
28, 2021, to December 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ear pillow. 
 
You asked the Plan to pre-approve the pillow. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is used for convenience purposes. 
 
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 pillow. Our reviewer says that the 
requested pillow is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the  requested ear pillow is not primarily medical in nature and therefore does not meet medical 
necessity guidelines. The submitted physician documentation does not include an ear pillow in the treatment 
plan. 
 
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 pillow have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an ear pillow.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99214) pulmonary function tests 
(94729, 94727) provided on February 23, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient services. You say that prior to switching to the Plan you were able 
to go to any doctor's office. You are on social security and do not have the means to pay such a hefty medical 
bill. The Plan denied your request. The Plan says enrollees must receive their medical services from an in-
network provider with the exception being urgent or emergent services. Non-emergent services with non-
contracted providers require prior authorization before services being rendered. 
 
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 office visit (99214) pulmonary 
function tests (94729, 94727) provided on February 23, 2022 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mass spectrometry and tandem mass spectrometry (eg, MS, 
MS/MS, MALDI, MS-TOF, QTOF), non-drug analyte(s) not elsewhere specified, qualitative or quantitative, 
each specimen (CPT code 83789). 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the records do not contain documentation to support the coding criteria. The Plan must follow 
Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare 
rules for coverage of the service have not been met. The testing is being used as specimen validity testing. 
Therefore, we decided that the Plan does not have to pay for mass spectrometry and tandem mass spectrometry 
(eg, MS, MS/MS, MALDI, MS-TOF, QTOF), non-drug analyte(s) not elsewhere specified, qualitative or 
quantitative, each specimen (CPT code 83789).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on March 15, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that the service provided to the enrollee was 
medically necessary and you would like the claim reprocessed for payment. The Plan denied your request. The 
Plan says the rendering provider is an OON provider and there was no 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 nursing facility care provided on March 15, 
2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the bone growth stimulator you received 
on September 28, 2021. 
 
You asked the Plan to waive the coinsurance for the bone growth stimulator. You say that you were never told 
this item would cost you anything. You said this item hurt you and did not help, so you quit using it after two 
weeks.  You said that you were told you could not return it. The Plan denied your request. The Plan says you 
were charged this cost sharing 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 20% 
coinsurance for durable medical equipment.  
 
You have been asked to pay 20% coinsurance for the bone growth stimulator. The bone growth stimulator falls 
within the durable medical equipment benefit category. This cost sharing applies regardless of the effectiveness 
of the item. This means that you have been asked to pay the correct amount based on your contract with the 
Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the bone growth stimulator you received 
on September 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on May 5, 2022. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they 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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on May 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction (92015) provided on March 8, 2022. 
 You asked the Plan to pay for the eye refraction. You say that you were not previously told that you would be 
responsible for the cost of this service. The Plan denied your request. The Plan says this refraction was 
performed with a medical eye exam. This service is only covered when performed as part of a routine (non-
medical) eye exam. Therefore, coverage criteria are not met in this case. 
 
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 one eye refraction per year when it is performed as part of a routine eye exam. 
 
We looked at the file and the Plan's rules. The record shows that the eye refraction in this case was performed 
as part of a medical (non-routine) eye exam. Based on this information, we decided that the Plan's rules for 
coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for 
the eye refraction (92015) provided on March 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Tecnis Eyhance deluxe astigmatism correcting intra-ocular 
lens (A-C IOL) (V2630, V2787) provided on March 3, 2022. 
 
You asked the Plan to pay for a deluxe A-C IOL. You say that this IOL is not experimental and was medically 
necessary. The Plan denied your request. The Plan says the astigmatism-correcting feature of an IOL is not 
covered by Medicare. 
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL 
during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a 
conventional IOL.  
 
While an A-C IOL may be appropriate for the enrollee, neither the Plan nor Medicare covers the astigmatism-
correcting feature of an IOL. Therefore, we decided that the Plan does not have to pay for a Tecnis Eyhance 
deluxe astigmatism correcting intra-ocular lens (A-C IOL) (V2630, V2787) provided on March 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on January 3, 2022. 
 
You asked the Plan to pay for the testing services. You say that the test was necessary for the management of 
the enrollee's advanced cancer. The Plan denied your request. The Plan says there is no evidence the referring 
physician was treating the enrollee. 
 The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. The testing is not supported in the records. The referring physician on 
the claim is different than the physician on the order form. There are insufficient medical records to show the 
intent for the testing to be ordered by the enrollees treating physician. Based on this information, we decided 
that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to 
pay for the lab testing services provided on January 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on March 29, 2022. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says while you are a 
member of our Plan you must use network providers to get your medical care and services. The only exceptions 
are emergencies, urgently needed services when the network is not available (generally, when you are out of 
the area), out-of-area dialysis services, and cases in which the Plan authorizes use of out-of-network providers. 
 
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 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on March 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a screening mammography (77067) provided on April 25, 
2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the screening mammography. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and prior authorization was not 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 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 screening 
mammography (77067) provided on April 25, 2022 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FoundationOne testing services provides on March 1, 2022. 
 
You asked the Plan to pay for the testing services. You say that the testing was necessary for the management 
of the enrollee's advanced cancer. The Plan denied your request. The Plan says that the testing is not a covered 
benefit. 
 
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. 
 
We looked at the file and the rules. The testing in this case was provided to a patient with a solid tumor. The 
FDA approval notice indicates that this panel is approved for solid tumors. No other valid denial rationale was 
presented by the Plan. The Plan has not made reasonable and diligent efforts to gather and forward to us 
information regarding their decision to deny your request.  Therefore, we decided that the Plan has to pay for 
the FoundationOne testing services provides on March 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99215) provided on March 29, 2022 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the services should be covered as you disagree with 
the charges. The Plan denied your request. The Plan says the services denied correctly as they were non-
emergent and prior authorization was not 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 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 an office visit (99215) provided on March 29, 
2022 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oncology gene expression profiling (81518) provided on 
March 11, 2022. 
 
You asked the Plan to pay for oncology gene expression profiling. You say that this is a medically necessary 
test which is covered by Medicare. The Plan denied your request. The Plan says this test was not billed in 
accordance with Medicare rules, as the required DEX Z-Code is missing from this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that to report a Molecular Diagnostic Test service in the state where this test was provided, the 
appropriate CPT code must be selected with one unit of service along with the appropriate DEX Z-Code 
identifier. We looked at the file and Medicare rules. This claim was not billed with the necessary DEX Z-Code. Based on 
this information, we decided that Medicare rules for coverage of oncology gene expression profiling have not 
been met. Therefore, we decided that the Plan does not have to pay for oncology gene expression profiling 
(81518) provided on March 11, 2022.