Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for DME and an injection provided on 
February 25, 2022. 
 
You asked the Plan to waive the coinsurance for DME and an injection. You say that you dont feel that you 
should owe anything. The Plan denied your request. The Plan says the coinsurance applied 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 20% 
coinsurance for DME and related supplies and 20% coinsurance for injections.  
 
 
 
 You have been asked to pay $40.38 which is 20% of the allowed amount for DME and an injection. The 
allowed amount for the DME is $178.36 (20% x $178.36 = $35.67). The allowed amount for the injection is 
$23.56 (20% x $23.56= $4.71).  DME falls within the Durable medical equipment (DME) and related supplies 
benefit category.  The injection falls within the Medicare Part B Prescription Drugs 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 coinsurance for DME and an injection provided on February 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on February 25, 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 the testing is not a covered 
benefit. 
 
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 gene panel in this case included the FANCC gene. Panels of 
tests with this gene is statutorily excluded. Based on this information, we decided that Medicare rules for 
coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for 
the gene panel testing provided on February 25, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from April 2, 2021, to April 
6, 2021, as billed with Diagnosis Related Group (DRG) 682. 
 
You asked the Plan to pay for inpatient care as billed with DRG 682. You say that these services were 
medically necessary and are supported in the record. The Plan denied your request. The Plan says DRG 682 is not appropriate as the diagnosis of acute kidney failure, unspecified (N17.9) is not supported in the medical 
record. The Plan argues that DRG 291 is more appropriate in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes. 
 
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 inpatient care as billed with DRG 682. Our 
reviewer says that the diagnosis of acute kidney failure, unspecified (N17.9) is not supported in the medical 
record for this inpatient admission. Our physician reviewer found that the documentation supports an admission 
for hypertensive heart and stage one through stage four chronic kidney disease (CKD) with heart failure. It is 
noted in the record that the enrollee has a history of stage four CKD and per the emergency room assessment, 
the enrollee has CKD with right upper extremity graft but not yet on hemodialysis. The enrollees creatinine 
level on admission was within the enrollees baseline for stage four CKD per the history and physical. 
Although the provider documented acute kidney injury, reasonable support within the health record must be 
present for that diagnosis. The review has determined that the medical records did not support the billing of 
acute kidney failure, unspecified (N17.9). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care as billed with DRG 682 have not been met. Therefore, we 
decided that the Plan does not have to pay for inpatient hospital care provided from April 2, 2021, to April 6, 
2021, as billed with Diagnosis Related Group (DRG) 682.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the foot orthotics provided on March 31, 2022. 
 
You asked the Plan to pay for the services provided. You say that you were not given a full benefit quote. The 
Plan denied your request. The Plan says that the service is not a covered benefit. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
The services at issue were provided by a contract provider. The file does not show that the Plan provided notice 
that the services provided would not be covered. For a service or item that is normally not covered, but could 
be covered under some conditions, the EOC alone is not adequate notice of non-coverage. Under Medicare 
rules, this means the services provided is considered approved by the Plan. Therefore, we decided that the Plan 
has to pay for the foot orthotics provided on March 31, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 10, 2021 billed 
with codes 81408, 81351, and 81320. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) 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 code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
September 10, 2021 billed with codes 81408, 81351, and 81320.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300) for a power 
wheelchair. 
 
You asked the Plan to pre-approve a power seat elevation system. You say that the requested feature is a 
medical necessity for you. The Plan denied your request. The Plan says the requested feature is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) and 
power standing feature (E2301) are non-covered because they are not primarily medical in nature. Based on 
this information, we decided that Medicare rules for coverage of a power seat elevation system have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system (E2300) 
for a power wheelchair.
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 16, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you disagree with the Plan's denial. 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 16, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Keytruda (J9271). 
 
You asked the Plan to pre-approve Keytruda. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says medical necessity rules for coverage have not been met 
because the requested drug has not been prescribed for a medically accepted indication. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Keytruda. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
FDA has not stated that the requested drug is indicated for the enrollee's condition. The Medicare-approved 
cancer-drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's 
clinical situation. No literature from Medicare-approved cancer journals was submitted for review. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Keytruda (J9271).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of torus mandibularis (D7473) and simple 
extractions (D7140) for teeth # 22, 23 and 24. 
 
You asked the Plan to pre-approve the dental services. You say that you need the bone filing so your dentures 
will fit. You also say that you need additional extractions. The Plan denied your request. The Plan says removal 
of torus mandibularis is not listed as a covered service. The Plan also says that the benefit limit of 8 simple 
extractions per year has 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, the requested removal of torus 
mandibularis is not among those covered under this benefit. Additionally, 8 simple extractions are covered 
every calendar year. The record shows that the Plan approved simple extractions for teeth # 6, 7, 8, 9, 11, 25, 
26 and 27, thus exhausting the benefit. Therefore, we decided that the Plan does not have to pre-approve 
removal of torus mandibularis (D7473) and simple extractions (D7140) for teeth # 22, 23 and 24.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5211) and a mandibular 
partial denture (D5212). 
 
You asked the Plan to pre-approve the partial dentures. You say that you started having teeth extracted in 
November 2021, with the goal of partials. You also say that you were not aware of the missing tooth clause 
prior to enrolling in this plan. The Plan denied your request. The Plan says you had teeth extracted or missing 
prior to becoming effective with the Plan on May 1, 2022. The Plan also says that you have not been 
continuously covered under this dental plan for more than 24 consecutive months. 
 
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 contract says waiting periods apply 
for teeth that were missing prior to becoming a enrolled in the Plan's dental coverage. Therefore, we decided 
that the Plan does not have to pre-approve a maxillary partial denture (D5211) and a mandibular partial denture 
(D5212).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve infusion services indicated by procedure codes 99601, 
99602 and S9338. 
 
You asked the Plan to pre-approve procedure codes 99601, 99602 and S9338. You say that the requested 
services are a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested 
codes are invalid for Medicare purposes. 
 
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 codes 99601, 99602 and S9338 have a Status Indicator of I on the Physician Fee 
Schedule. This means that procedure codes 99601, 99602 and S9338 are not valid for Medicare purposes. 
Based on this information, we decided that Medicare rules for coverage of procedure codes 99601, 99602 and S9338 have not been met. Therefore, we decided that the Plan does not have to pre-approve infusion services 
indicated by procedure codes 99601, 99602 and S9338.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve upper and lower dentures. 
 
You asked the Plan to pre-approve dentures. You say that these dentures are medically necessary as you do not 
have any teeth left. The Plan denied your request. The Plan says dentures are not covered by your dental 
benefit. 
 
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 pre-approve 
upper and lower dentures.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the requested bone marrow aspirate 
remains experimental in nature, as more research is needed to support its use. The services are therefore not 
reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bone marrow aspirate.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diabetic equipment (K0553, K0554) purchased on 
January 26, 2022. 
 
You asked the Plan to pay for the diabetic equipment. You say that you would like this claim reprocessed based 
on the documentation submitted. The Plan denied your request. The Plan says required documentation is 
missing for payment to be approved. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
 
 
 The record does not contain a valid proof of delivery. In this case, the proof of delivery does not include 
documentation, such as a packing slip, to indicate the items that were ordered. Without this, the proof of 
delivery will not be considered valid as there is no documentation of the specific items that were provided. The 
record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for the diabetic equipment (K0553, K0554) purchased 
on January 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2750) provided by a participating provider. 
 
You asked the Plan to pre-approve the dental services. You say that you have not had a crown in 20 years. 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 29, 2019. 
Therefore, we decided that the Plan does not have to pre-approve a crown (D2750) provided by a participating 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on March 2, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says prior authorization must be obtained prior to out-of-
network services being rendered, and this was not authorized. 
 
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 domiciliary or rest home visit provided on 
March 2, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and x-ray provided on March 14, 2022, by an 
OON provider. 
 
You asked the Plan to pay for an office visit and x-ray. You say that you would like these services reconsidered 
because, despite being understaffed, you believe they did not stop providing services to the enrollee. The Plan 
denied your request. The Plan says the out-of-network services were not authorized. 
 
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 and x-ray provided on March 14, 
2022, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a crown (D2740) for tooth #18. 
 
You asked the Plan to pre-approve a crown. You say that the service is medically necessary. The Plan denied 
your request. The Plan says that the service at issue is not medically necessary. 
 
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. The Plan covers a crown 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 a crown. Our reviewer says that the 
service is medically reasonable and necessary. Our physician reviewer found the documentation indicates that 
there is a distal fracture of the porcelain on the crown. It is medically reasonable and necessary to replace the 
defective crown. Repairs to fractured porcelain do not hold up to masticatory forces applied to molar teeth. 
 
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 a crown have been met. Therefore, we decided that the Plan has to pre-approve 
a crown (D2740) for tooth #18.  
 
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 acupuncture services provided on December 28, 2021. 
 
You asked the Plan to pay for acupuncture services. The Plan denied your request. The Plan says a licensed 
acupuncturist is a non-covered provider type and the provider is not supervised by any physician, physician 
assistant, nurse practitioner or a clinical nurse specialist.  
 
  The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, a licensed acupuncturist is a non-covered provider 
type and the provider is not supervised by any physician, physician assistant, nurse practitioner or a clinical 
nurse specialist. Therefore, we decided that the Plan does not have to pay for acupuncture services provided on 
December 28, 2021.