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

 
We decided that the Plan does not have to waive the copayment for primary care (PCP) services provided in 
conjunction with an annual wellness visit on March 17, 2022. 
 
You asked the Plan to waive the copayment for the PCP services. You say that you should not have a 
copayment for your annual wellness visit. The Plan denied your request. The Plan says you have been 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 no 
coinsurance, copayment, or deductible for the annual wellness visit. You will be responsible for cost sharing 
amounts for any laboratory, radiology, or diagnostic testing performed during the visit. 
 Your contract with the Plan also clearly says that you must pay a $10 copayment for primary care provider 
(PCP) services. 
 
The file shows that the provider administered a urinalysis test during the wellness visit. This test goes beyond 
the scope of the wellness visit, and is subject to cost sharing. Therefore, you have been asked to pay a $10 
copayment for the PCP services. The PCP services fall 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 primary 
care (PCP) services provided in conjunction with an annual wellness visit on March 17, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from June 
15, 2021, to June 18, 2021. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that you needed a second surgery to 
repair damage caused by a previous procedure. You say that the facility should be responsible for all costs of 
the second surgery. The Plan denied your request. The Plan says you have been 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 $325 per 
day for days 1-5 for each inpatient admission.  
 
The file shows that you were in the hospital from June 15, 2021, to June 18, 2021. Since there is no copayment 
for the discharge date, you have been asked to pay $325 per day for days 1-3 of inpatient care. The total for 
your stay is $975 ($325 copayment x 3 days = $975). The inpatient care 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 inpatient hospital care provided 
from June 15, 2021, to June 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that this will be used for treatment of the enrollee's 
conditions. The Plan denied your request. The Plan says the denial of authorization for this device is correct, 
because a ventilator is not covered for positive airway pressure therapy regardless of the underlying medical 
condition. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilators used to provide positive airway 
pressure therapy, regardless of the underlying medical condition, are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
portable ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on April 
25, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not aware that the service would not 
be covered. 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 28, 2020. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on April 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prostheses additions (prosthetic advanced foot and ankle 
and shock reducing pylon) identified with codes L5988, L5968, and L5981. 
 
You asked the Plan to pre-approve prostheses additions. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested items are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that additions to prostheses are only covered for certain 
indications. 
 
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 prostheses additions. Our reviewer says 
that the documentation does not support that the requested items are medically reasonable or necessary. Our 
physician reviewer found you underwent a left transtibial amputation in January of 2021 due a long-standing 
history of Charcot ankle. A clinical progress note dated May 20, 2022 indicated that you were ready for the 
fitting of a permanent prosthesis. You are wearing his temporary prosthesis daily. The physical examination 
showed 5 out of 5 upper extremity strength and 4 out of 5 lower extremity strength. Your left residual limb 
shows some scarring and no drainage. There was some redness which had improved. Range of motion at the 
knee is preserved. A prosthetic evaluation was performed on June 3, 2022 and indicated that you walk with a 
cane. The skin of his residual limb is noted to be normal as well as the limb shape. No contracture or edema is 
present. Range of motion and muscle strength is within functional limits. You are noted to have the potential to 
be a K3 level ambulator. A clinical progress note dated May 20, 2022 indicates that you are using a cane to 
ambulate at home and on flat surfaces and is using a walker outside. It indicates that you need to negotiate 
stairs and uneven surfaces, but it is not clear what your K or ambulatory level is anticipated to be. It may 
potentially be K2 or K3 given the description and there is no documentation from physical therapy regarding 
your current mobility status. It is not possible to determine if the requested prosthetic advanced foot and ankle 
and shock reducing pylon is necessary without this information. Therefore, you do not meet criteria for the 
requested items. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prostheses additions have not been met. Therefore, we decided that the Plan 
does not have to pre-approve prostheses additions (prosthetic advanced foot and ankle and shock reducing 
pylon) identified with codes L5988, L5968, and L5981.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. 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. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found you do not have documented skilled 
nursing needs or skilled therapy needs. Daily skilled services are not required to establish a maintenance 
program or to prevent deterioration of your condition. Your care needs are custodial and can, as a practical 
matter, be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for computed tomography (CT scan) on April 
11, 2022. 
 
You asked the Plan to waive the copayment for CT scan. You say that this should be covered because you 
would like this reduced as this was a follow-up from a previous scan. You dont understand why you were 
charged for a follow-up. The Plan denied your request. The Plan says the cost sharing you are being charged is 
correct. 
 
 
 
 
 
 
 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 $250 
copayment per day for other Medicare-covered diagnostic radiology services that are not ultrasounds. You will 
only pay one copayment per day even if multiple diagnostic radiology services are performed. Covered 
services include, but are not limited to diagnostic radiology services, such as ultrasound, nuclear cardiac 
imaging, PET, MRI, and CT scan. The Provider billed in the amount of $1,095 and the allowed amount is 
$130.16. This is less than the copayment. Therefore, results in the total cost sharing amount of $130.16. 
 
You have been asked to pay a $130.16 copayment, which is less than the copayment for CT scan. CT scans fall 
within the Outpatient diagnostic tests and therapeutic services and supplies 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 computed tomography (CT scan) on April 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service March 28, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that [Enter appthis code should be separately 
payable. The Plan denied your request. The Plan says procedure code 99100 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service March 28, 2022.
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 patient meets criteria for LTACH 
care. The Plan denied your request. The Plan says the patient's medical needs are being met in the current 
setting. With additional time in the current acute setting, clinical stability can be ensured such that an 
appropriate level of care can be determined. 
 
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 the patient is a 70 year-old male who was admitted to the acute care hospital with 
acute respiratory failure and cerebellar infarction requiring craniotomy, evacuation of hematoma, drain (EVD) 
placement, and intubation. Trach and PEG were placed. The EVD was removed. Recent documentation 
describes the patient as awake and following commands, off vent support, and tolerating trach mask, but is still 
requiring additional weaning and voiding trials as he has a Foley. The patient appears to be more stable and 
improving and should only require short-term additional acute care services that can safely be administered at the current facility until more appropriate for a lower level of care. The patient does not require services at the 
LTACH that are not already available at the current facility. Transfer to LTACH is not medically necessary as 
it would not be clinically advantageous. Completion of treatment at the current facility is 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 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 fluoroscopic guidance with injection of contrast provided on 
December 14, 2021. 
 
You asked the Plan to pay for fluoroscopic guidance with injection of contrast. You say that fluoroscopic 
guidance with injection of contrast is medically necessary. The Plan denied your request. The Plan says 
fluoroscopic guidance with injection of contrast 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 fluoroscopic guidance with injection of 
contrast. Our reviewer says that fluoroscopic guidance with injection of contrast is not considered medically 
reasonable and necessary. Our physician reviewer found that the review of the published medical literature 
shows that routine use of imaging procedures (such as, x-ray, CT, MRI, arthrography, and ultrasound) for the purpose of visualization of the knee to provide guidance for needle placement, may not improve clinical 
outcomes and are not medically necessary.  However, fluoroscopy, with or without contrast, may be medically 
necessary if documentation supports that the presentation of the affected knee on the day of the procedure 
makes needle insertion problematic. In this case, the medical records do not document any significant 
deformities, atypical anatomy, bony enlargement, excessive osteophytes, or limited joint space of the knee. The 
review has determined that the services at issue in this case are 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 fluoroscopic guidance with injection of contrast have not been met. Therefore, 
we decided that the Plan does not have to pay for fluoroscopic guidance with injection of contrast provided on 
December 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opzelura cream. 
 
You asked the Plan to pre-approve self-administered drug. You say that you are appealing this denial. The Plan 
denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not 
covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug 
benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Opzelura cream.  
 
Benefits for self-administered drug may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), bite wing radiographic 
images (D0270), and a cone beam computed tomography capture and interpretation (D0364) provided on April 
12, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not aware that the services were not 
covered. The Plan denied your request. The Plan says your benefit for the limited oral evaluation and the 
bitewing radiographic image have already been exhausted. The cone beam computed tomography capture and 
interpretation 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 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 bitewing radiographic image was exhausted on date of service February 2, 2022, and 
your benefit for the limited oral evaluation was exhausted on date of service March 30, 2022. The cone beam 
computed tomography capture and interpretation is not a covered benefit. Therefore, we decided that the Plan 
does not have to pay for a limited oral evaluation (D0140), bite wing radiographic images (D0270), and a cone 
beam computed tomography capture and interpretation (D0364) provided on April 12, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that this drug is medically necessary for your condition. 
The Plan denied your request. The Plan says step therapy criteria have not been satisfied. 
 
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 Euflexxa. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found the Plan requires a 
trial of Orthovisc, Synvisc, or Synvisc One before they will approve the requested drug. In this case, you have 
not tried and failed the required drug(s). There is no documentation provided indicating that the Plans required 
drug(s) would likely be less effective and/or likely have adverse effects for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for toilet-to-tub sliding transfer bench, lift chair, bidet toilet seat, 
and a lifting toilet seat purchased from November 23, 2021, through December 7, 2021, from an out-of-
network provider. 
 
You asked the Plan to pay for the out-of-network purchases. You say that you had to update your home to 
accommodate the enrollee. You state were provided misinformation from the Plan. The Plan denied your 
request. The Plan says no prior authorization was requested for the DME supplies that were purchased. 
 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 toilet-to-tub sliding transfer bench, lift chair, bidet 
toilet seat, and a lifting toilet seat purchased from November 23, 2021, through December 7, 2021, from an out-
of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Tempus xF testing (CPT code(s): 81292, 81295, 81206, 
81235) provided on December 2, 2021. 
 
You asked the Plan to pay for Tempus xF testing. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not covered as billed. 
 
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 Tempus xF testing have not been met. Your request does not meet 
Medicare rules as the testing performed was not FDA approved. In addition, the claim submitted was found to 
include multiple genes billed individually, using T1 codes, which were all part of a genomic sequencing panel.  
Per the Centers for Medicare and Medicaid Services National Correct Coding Initiative Coding Policy Manual, 
if one laboratory procedure evaluates multiple genes using a next generation sequencing procedure, the 
laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte 
assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis CPT code. If no CPT 
code accurately describes the procedure performed, the laboratory may report CPT code 81479 (Unlisted 
molecular pathology procedure) with one unit of service or may report multiple individual CPT codes 
describing the component test results when medically reasonable and necessary. Procedures reported together 
must be both medically reasonable and necessary (e.g., sequencing of procedures) and ordered by the physician 
who is treating the beneficiary and using the results in the management of the beneficiary's specific medical 
problem. Your request for Tempus xF testing is not medically necessary. Therefore, we decided that the Plan 
does not have to pay for Tempus xF testing (CPT code(s): 81292, 81295, 81206, 81235) provided on December 
2, 2021.