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

 
We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that this would improve the enrollee's quality of life. 
The Plan denied your request. The Plan says that this is considered experimental and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The Intracept 
procedure is experimental. More research is needed. Our physician reviewer found that the enrollee's condition 
does not meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure for the enrollee.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthovisc. 
 
You asked the Plan to pre-approve Orthovisc. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been 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 Orthovisc. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the record does not indicate that the 
enrollee has a contraindication to, or would have an adverse effect from the plan's preferred step one 
alternative. The elements of the coverage criteria are not satisfied. The requested service cannot be 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orthovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Orthovisc.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on November 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 procedure code 85706 is not supported. 
 
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 87506 is infectious agent detection by nucleic acid (DNA 
or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), 
includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple 
types or subtypes, 6-11 targets. 
 
We find that CPT code 87506 is not supported in the medical record. Specifically, there is no documentatino of 
infectious agent detection of a gastrointestinal pathogen, 6-11 targets. 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 pay for the laboratory services rendered on November 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory panel rendered on January 24, 2022. 
 
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 are not covered. 
 
The Plan must follow Medicare rules. The rules say that multiplex PCR respiratory viral panels of 6 or more 
pathogens are non-covered. 
 
We looked at the file and Medicare rules. The file shows that 6 or more pathogens were tested. Therefore, we 
decided that the Plan does not have to pay for the respiratory panel rendered on January 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) test (0037U) provided 
January 19, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the provision of F1CDx to the enrollee 
meets the requirements of the NCD and has been determined by CMS to be reasonable and necessary for the 
management of the enrollee's advanced cancer. The Plan denied your request. The Plan says does not meet 
Medicare NCD/LCD criteria. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The next generation sequence testing (NGS) testing panel performed 
included testing for the FANCC gene. Testing for this gene is not a Medicare benefit and is statutorily excluded 
service. In addition to single gene testing, panels that include the FANCC gene are statutorily excluded service. 
Based on this information, we decided that Medicare rules for coverage of the laboratory services have not 
been met. Therefore, we decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) test 
(0037U) provided January 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC testing rendered on March 25, 2022. 
 
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 testing is not covered. 
 
The Plan must follow Medicare rules. The rules say that MolDX will reimburse approved tests covered for 
dates of service. 
 
We looked at the file and Medicare rules. The test at issue was not approved by the MolDx program for the 
billed date of service. 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 pay for the DecisionDx-SCC testing 
rendered on March 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 24, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied 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 an office visit provided on January 24, 2022, by an 
out-of-network (OON) provider.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve 4 home health occupational therapy visits. 
 
You asked the Plan to pre-approve home health services. You say that the services are necessary. The Plan 
denied your request. The Plan says that based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are medically necessary. Our physician reviewer found the requested occupational 
therapy is intermittent in nature and reasonable and necessary given your decline in function and ability to 
perform basic daily activities. Two visits of occupational therapy would be insufficient to address your 
functional deficits as well as provide education and ensure a transition to home exercise program. It does not 
entail venipuncture or obtaining blood samples. Therefore, the additional 4 visits of home health occupational 
therapy can be considered 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 home health services have been met. Therefore, we decided that the Plan has to 
pre-approve 4 home health occupational therapy visits.  
 
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 pre-approve an immediate lower denture (D5140), implant 
placement (D6010 x 6), and extractions (D7210 x 7), to be performed by an out-of-network provider. 
 
You asked the Plan to pre-approve the dental services. You say that you would like to continue seeing this out-
of-network provider. The Plan denied your request. The Plan says dental services from an out-of-network 
provider are not covered by your supplemental benefits. 
 
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. 
 
You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested denture and extractions are not covered under this benefit when 
received from an out-of-network provider. The record also shows there are in-network providers available. 
Additionally, the requested implant placements are not covered under the enrollee's benefit regardless of the 
provider's network status. Therefore, we decided that the Plan does not have to pre-approve an immediate 
lower denture (D5140), implant placement (D6010 x 6), and extractions (D7210 x 7), to be performed by an 
out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on October 4, 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 procedure code 87798 is not supported. 
 
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 87798 is infectious agent detection by nucleic acid (DNA 
or RNA), not otherwise specified; amplified probe technique, each organism. 
 We find that CPT code 87798 is not supported in the medical record. Specifically, the records do not support a 
repeat clinical laboratory test was performed. 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 pay for the 
laboratory services rendered on October 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a core build up (D2954) provided by a participating provider 
on April 22, 2022. 
 
You asked the Plan to pay for a core build up. You say that you feel this should be covered under crown 
benefits. The Plan denied your request. The Plan says D2950 is not 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, 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 core 
build up (D2954) provided by a participating provider on April 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete denture - mandibular (D5120), complete denture 
- maxillary (D5110), extraction, erupted tooth (D7210) and extraction, erupted tooth, or exposed root  (D7140) 
provided on February 10, 2022, and March 24, 2022. 
 
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says your benefit for 
the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 24, 2022. 
Therefore, we decided that the Plan does not have to pay for a complete denture - mandibular (D5120), 
complete denture - maxillary (D5110), extraction, erupted tooth requiring removal of bone (D7210) and 
extraction, erupted tooth, or exposed root  (D7140) provided on February 10, 2022, and March 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown on tooth #7, 8, 10, and 18 (D2740). 
 
You asked the Plan to pre-approve the crowns. You say that your front teeth are broken. The Plan denied your 
request. The Plan says the teeth do not appear to have significant breakdown due to decay or trauma. 
 
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. The Plan covers the crowns 
when the services are medically necessary and reasonable.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the crowns. Our reviewer says that the 
coverage criteria has not been met. Our physician reviewer found that the teeth in question do not have 
significant pathologic destruction to any tooth in the order of half or more of the coronal structure.  Tooth #18, 
a molar, does not exhibit destruction of fur of more surfaces and two cusps as required by the criteria.  The 
anterior teeth show only some incisal wear, and not the four or more surfaces required under the Plan criteria.  
Given the lack of extensive breakdown of the anterior and posterior teeth, crowns would not be indicated under 
the Plan criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crowns have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a crown on tooth #7, 8, 10, and 18 (D2740).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), complete series 
x-ray (D0210), and prophylaxis (D1110) provided on April 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that the plan did not send any communication to the 
provider's office notifying them they were no longer in network. You also say that this should be covered. The 
Plan denied your request. The Plan says the dental services were performed from an out-of-network provider 
and are not covered by the enrollee's supplemental benefits. 
 
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. 
 
The record shows the dental services were performed by an out-of-network provider. Though the enrollee's 
Plan offers a dental benefit in excess of Medicare coverage, the dental services are not covered under this 
benefit when performed by an out-of-network provider. Therefore, we decided that the Plan does not have to 
pay for the comprehensive oral evaluation (D0150), complete series x-ray (D0210), and prophylaxis (D1110) 
provided on April 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for periodontal scaling and root planing - four 
or more teeth per quadrant (D4341) provided on January 4, 2022. 
 
You asked the Plan to waive the copayment for the scaling and root planing. The Plan denied your request. The 
Plan says the copayment was 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 $61 
copayment for copayment for periodontal scaling and root planing - four or more teeth per quadrant (D4341).  
 
You have been asked to pay $122 ($61 copay x 2 teeth) for the scaling and root planing (D4341). The scaling 
and root planing falls within the Dental Services - Periodontics 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 periodontal scaling and root planing - four or more teeth per quadrant (D4341) 
provided on January 4, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional hours of home care beyond 4 hours per day from 
January 13, 2022, to February 2, 2022. 
 
You asked the Plan to pay for the home care. You say that due to an outbreak of COVID-19 in the skilled 
nursing facility, you felt it was best for the enrollee to be discharged home with home care. The Plan denied 
your request. The Plan says 21 days at four hours a day have been covered by the Plan. The Plan also says 
additional hours cannot be approved. 
 
The Plan must follow Medicare rules. The rules say that home health aide services are covered at less than 8 
hours per day and 28 or fewer hours each week. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home care have not been met. Specifically, 24-hour care is never covered, as 8 hours a day or 
less are covered. The services provided were not skilled, and additional hours cannot be considered medically 
necessary. Therefore, we decided that the Plan does not have to pay for additional hours of home care beyond 4 
hours per day from January 13, 2022, to February 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the periodic oral evaluation (D0120) and prophylaxis 
(D1110) provided on April 7, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay more for the periodic oral evaluation and prophylaxis. You say that you do not feel it 
is right for the Plan to pay such a small amount on a claim. The Plan denied your request. The Plan says you 
are responsible for any charged amount above the Plan's 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 Plan's coverage rules apply in this case. 
 
You have been asked to pay the difference between the out-of-network provider's charges and the Plan's 
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 the periodic oral evaluation (D0120) and 
prophylaxis (D1110) provided on April 7, 2022 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by a participating 
provider on March 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that you needed this exam done. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 11, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by a 
participating provider on March 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scalings and root planings (D4341) of the 
lower left, lower right, upper left, and upper right quadrants. 
 
You asked the Plan to pre-approve the scalings and planings. The Plan denied your request. The Plan says your 
benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 10, 2020. 
Therefore, we decided that the Plan does not have to pre-approve periodontal scalings and root planings 
(D4341) of the lower left, lower right, upper left, and upper right quadrants.