Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the impacted tooth removal (D7241), removal of torus 
mandibularis (D7473) and therapeutic parenteral drugs (D9612). 
 
You asked the Plan to pre-approve the impacted tooth removal (D7241), removal of torus mandibularis 
(D7473) and therapeutic parenteral drugs (D9612). The Plan denied your request. The Plan says the services 
are not covered 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. 
 
  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 the 
impacted tooth removal (D7241), removal of torus mandibularis (D7473) and therapeutic parenteral drugs 
(D9612).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray services coded 73562 provided on June 7, 2021. 
 
You asked the Plan to pay for the x-ray services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 73562 is not supported in the medical record. Specifically, a claim with this code has 
already been processed and paid by the Plan. Duplicate radiology reports were submitted with the appeal 
supporting only one set of x-rays were taken per knee. This means this claim is a duplicate and cannot be paid. 
Based on this information, we decided that Medicare rules for coverage of the x-ray services have not been 
met. Therefore, we decided that the Plan does not have to pay for the x-ray services coded 73562 provided on 
June 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the debridement of subcutaneous tissue (11042) rendered from May 24, 2021, to June 07, 2021.

You asked the Plan to waive the copayment for the debridement of subcutaneous tissue. You say that you never pay a fee for this service, just the copayment for an office visit. You also say you do not agree with paying this bill for the provider to clean and bandage with a gauze pad on a weekly basis, and someone is over charging. The Plan denied your request. The Plan says you were charged the correct copayment 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 a $250 copayment per visit for outpatient surgery or procedure at a hospital facility. 

You have been asked to pay a $250 copayment per visit for two visits of the debridement of subcutaneous tissue from May 24, 2021, to June 7, 2021, which is a total of $500 ($250 x 2 = $500). The debridement of subcutaneous tissue falls within the Outpatient Surgery, including services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 the debridement of subcutaneous tissue (11042) rendered from May 24, 2021, to June 07, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services (90834) provided on June 17, 2021, 
by a provider not enrolled in the Medicare program. 
 
You asked the Plan to pay for psychotherapy services. You say that the requested services were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
  The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90834) 
provided on June 17, 2021, by a provider not enrolled in the Medicare program.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for in office services provided to the enrollee on September 18, 
2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there was no authorization for these services. 
 
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 in office services provided to the enrollee on 
September 18, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services you received on July 2, 
2021. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you had a possible bowel 
obstruction and your primary care doctor told you to call an ambulance. The Plan denied your request. The 
Plan says you were charged this copayment 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 $200 
copayment per trip for ambulance services.  
 
You have been asked to pay a $200 copayment per trip for the ambulance services. This copayment applies 
regardless of the reason for the ambulance services. 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 
ambulance services you received on July 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires prolonged 
hospitalization and close physician monitoring for multiple conditions and would be best served at an LTACH. 
The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met. The enrollee 
is not medically stable and is receiving the appropriate care in the current acute care facility. 
 
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 there is no documentation provided indicating medical necessity for admission to a 
LTACH. The enrollee is receiving appropriate care at the present acute care hospital.  The enrollee does not require services at the LTACH that are not available at the acute care hospital where he 
is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be 
furnished safely and effectively only on an inpatient basis. 
 
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 LTACH services.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for Guardant360 testing provided on August 4, 2021. 
 
You asked the Plan to pay for genetic testing. You say that this testing was ordered by the in-network treating 
physician to determine the optimal treatment pathway for the enrollee. The Plan denied your request. The Plan 
says that the denial of payment for this testing is correct, because prior authorization was requested and denied 
by the Plan. 
 
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. 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 has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not specify whether the ordering physician was in-network or out-
of-network with the Plan. The documentation submitted does not include prior notice from the Plan that this 
service would not be covered. Although the Plan claims that they issued a denial of prior authorization on 
August 4, 2021, the Notice of Denial of Medical Coverage included in the file has a date of August 27, 2021. 
Therefore, the Plan has not supported that the Plan issued adequate prior notice of non-coverage. Without this 
information, we cannot determine whether the lab order made constituted plan-directed care. Therefore, the 
Plan has not shown that its decision to deny payment for this testing is correct or justified according to 
Medicare rules. Therefore, we decided that the Plan has to pay for Guardant360 testing provided on August 4, 
2021.  
 
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 pre-approve BRAF genetic testing. 
 
You asked the Plan to pre-approve BRAF genetic testing. You say that the requested genetic testing is 
medically necessary. The Plan denied your request. The Plan says BRAF genetic testing is not medically 
reasonable and necessary in this case. 
 
The Plan follows Medicare rules. Medicare rules say that genetic testing is covered for certain clinical 
indications and when medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve BRAF genetic testing. Our reviewer 
says that the criteria for coverage have not been met. Our physician reviewer found the requested genetic 
testing is not medically necessary. The enrollee does not need this testing to determine if a Medicare covered 
therapy is a reasonable option given his specific clinical presentation. The enrollee has a diagnosis of 
Waldenstrom macroglobulinemia with symptomatic cryoglobulinemia and hyperviscosity. The records do not 
show that the enrollee has malignant melanoma, non-small cell lung cancer, hairy cell leukemia, or metastatic 
colorectal cancer. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of BRAF genetic testing have not been met. Therefore, we decided that the Plan 
does not have to pre-approve BRAF genetic testing.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral, periapical first radiographic image (D0220), 
additional periapical radiographic image (D0230) and bitewing radiographic images (D0274) provided on 
August 12, 2021. 
 You asked the Plan to pay for the radiographic images. You say that you would like reconsideration because 
these services were part of your comprehensive oral exam and should be covered. The Plan denied your 
request. The Plan says the procedure codes billed are not listed as covered services and are not covered 
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. 
 
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 the 
intraoral, periapical first radiographic image (D0220), additional periapical radiographic image (D0230) and 
bitewing radiographic images (D0274) provided on August 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for radiofrequency ablation of paravertebral facet joint nerves (64635, 64636) provided on April 28, 2021, by an out-of-network provider.

You asked the Plan to pay for radiofrequency ablation of paravertebral facet joint nerves. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for out-of-network care have not been met.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 radiofrequency ablation of paravertebral facet joint nerves (64635, 64636) provided on April 28, 2021, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an occlusal guard (D9944) provided by a participating 
provider.  
 
You asked the Plan to pay for an occlusal guard. You say that you need this guard because you grind your 
teeth. The Plan denied your request. The Plan says the mouth guard being requested is not a covered benefit. 
 
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, 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 an 
occlusal guard (D9944) provided by a participating provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgery services provided on March 22, 2021.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed codes cannot be verified.

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 22854 is insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to vertebral corpectomy(ies) (vertebral body resection, partial or complete) defect, in conjunction with interbody arthrodesis, each contiguous defect.

The CPT Code Manual definition of code 63082 is vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, each additional segment.

We find that CPT codes at issue are not supported in the medical record. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the surgery services provided on March 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant Reveal testing (81479) provided on July 23, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Guardant Reveal testing. You say that this is covered by Medicare. The Plan 
denied your request. The Plan says 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 Guardant Reveal testing (81479) provided on July 
23, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided by an out-of-network provider on 
August 19, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
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 had network providers 
available who could have provided the services at issue in this appeal. 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 the services provided by an out-of-network provider on August 
19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the services could be provided in another setting, such as an acute 
rehabilitation facility, skilled nursing facility. 
 
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 there is no documentation provided indicating medical necessity for admission to a 
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where he is currently receiving 
care. There are no services available at the LTACH that the enrollee requires that are not available at the health 
care setting being offered by the health plan.  
 The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870). 
 
You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested procedure is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met 
because the requested procedure is experimental/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 a Vertiflex procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that two orthopedic societies have published recommendations of non-support for the 
requested procedure. The procedure is still considered experimental. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Vertiflex procedure (22869, 22870).