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

 
We decided that the Plan does not have to pre-approve an office visit with an oncologist to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that you are in severe pain and are requesting 
reconsideration for the denial of the OON provider. The Plan denied your request. The Plan says your records 
received do not indicate that you have an emergent or urgent medical condition or need specialized services 
that are not available in the network. The Plan also says there are ten in-network providers available. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit with an oncologist to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses provided on January 20, 2022. 
 
You asked the Plan to pay for the eyeglasses. You say that your benefit covers up to $125 for eyeglasses, and 
you should be reimbursed for these services. The Plan denied your request. The Plan says you previously received eyeglasses on January 9, 2021, which were covered by the Plan less than two years ago. Your Plan 
pays up to $125 for eyeglasses and contact lenses once every 24 months. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services up to $125 once every 24 months. 
 
We looked at the file and the Plan's rules. The record shows that you last used and exhausted your eyewear 
benefit in January of 2021, which is less than 24 months before the date in question. Based on this information, 
we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that 
the Plan does not have to pay for the eyeglasses provided on January 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for labs services (88104, 88305, 88312, 88361) provided August 
27, 2021. 
 
You asked the Plan to pay for the labs services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the claim was not submitted with a valid place of service. 
 
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 codes 88104, 88305, 88312, & 88361 are not supported in the medical record. Specifically, 
the serices has a professional component / technical component indicator of 1 but were not billed on the facility 
claim. Based on this information, we decided that Medicare rules for coverage of the labs services have not 
been met. Therefore, we decided that the Plan does not have to pay for labs services (88104, 88305, 88312, 
88361) provided August 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676). 
 
You asked the Plan to pay for a pneumatic compression device. You say that this service was medically 
necessary. The Plan denied your request. The Plan says this device is non-covered. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0676).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to waive the charges for the outpatient hospital observation stay and 
oral/topical drugs administered during this stay from December 16, 2021, through December 18, 2021. 
 
You asked the Plan to waive the charges for the observation stay and self-administered drugs. You say that you 
had to be sent back to the hospital due to their error regarding your positive COVID test. You would not have 
had to pay this copayment if not due to this error, and as such, you feel it should be waived. The Plan denied 
your request. The Plan says you were admitted for observation care on December 16, 2021. The observation 
copayment was correctly applied. The Part D drugs were also correctly denied and can be reimbursed by the 
Part D plan. 
 
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 $90 
copayment for outpatient hospital observation visits. The rules also say that Medicare Part B does not cover 
self-administered drugs provided in the outpatient setting. 
 
You have been asked to pay a $90 copayment for the observation stay. The drugs that were denied are not 
among the self-administered drugs that Medicare Part B covers. 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 
charges for the outpatient hospital observation stay and oral/topical drugs administered during this stay from 
December 16, 2021, through December 18, 2021.  
 
Benefits for the self-administered drugs 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs the oversight of a podiatrist and 
intense therapy to regain maximum function. The Plan denied your request. The Plan says the medical records 
do not support the need for an intensive rehabilitation therapy program consisting of at least 3 hours of therapy 
per day at least 5 days per week. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  Our physician reviewer found the enrollee was admitted for surgical management of an ankle fracture. Medical 
problems are stable. Our physician reviewer found there are no complex nursing or rehabilitation needs. While 
you have a need for physical or occupational therapy, there is no documentation of a need for an intensive 
rehabilitation program. Medically necessary care can be provided in a different 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) test (0037U) provided 
January 11, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that this test is medically necessary and is used 
to help determine treatment options. 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 0037U is targeted genomic sequence analysis, solid organ neoplasm, DNA analysis of 324 genes, interrogation for sequence variants, gene copy number amplifications, 
gene rearrangements, microsatellite instability and tumor mutational burden. 
 
We find that CPT code 0037U is not supported in the medical record. Specifically, 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 11, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for four (4) units of intravascular ultrasound (noncoronary 
vessel) (37253) provided on January 7, 2022. 
 
You asked the Plan to pay for four units of intravascular ultrasound. You say that these services are supported 
in the record as billed. The Plan denied your request. The Plan says this service is not supported in the medical 
record for the number of units billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. In this case, the CPT Code Manual definition of code 37253 is intravascular 
ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including 
radiological supervision and interpretation; each additional noncoronary vessel (List separately in addition to 
code for primary procedure). 
 We asked our coder 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 four units of intravascular ultrasound. Our reviewer says that 
the records provided do not support four units of this service. Our reviewer found the procedure report states, "I 
inserted the intravascular ultrasound catheter and I performed intravascular ultrasound of the superior vena 
cava, inferior vena cava, right common iliac vein, right external iliac vein and right common femoral vein." In 
this case, four units of this service cannot be verified. 
 
We looked at this coders review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of four units of intravascular ultrasound have not been met. Therefore, we decided 
that the Plan does not have to pay for four (4) units of intravascular ultrasound (noncoronary vessel) (37253) 
provided on January 7, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan of the whole body. 
 
You asked the Plan to pre-approve the requested CT scan. You say that the scan is the new standard of care for 
lytic bone lesions. The Plan denied your request. The Plan says that the enrollee has not undergone any other 
studies to rule out lytic lesions. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 the requested CT scan. Our physician 
reviewer found a low dose CT scan is a standard of care supported by the National Comprehensive Cancer 
Network (NCCN) guidelines for the work-up of multiple myeloma. It is reasonable and medically necessary for 
this enrollee with possible smoldering myeloma. 
 
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 requested CT scan have been met. Therefore, we decided that the Plan has 
to pre-approve a computed tomography (CT) scan of the whole body.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a foot, removable, molded to patient model insert 
(L3020x2). 
 
You asked the Plan to pre-approve foot orthotics. You say that the requested inserts are medically necessary 
because the orthotics will help with your balance weight and altered gait. The Plan denied your request. The 
Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve a foot, removable, molded to 
patient model insert (L3020x2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an excision of upper torus palatinus (21032). 
 
You asked the Plan to pre-approve an excision of upper torus palatinus. You say that the enrollees teeth have 
been going downhill with significant pain all over. The enrollee would like to have all her teeth extracted in 
preparation for dentures. The Plan denied your request. The Plan says the requested service is not a covered 
benefit with your Plan. 
 
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 an 
excision of upper torus palatinus (21032).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on August 28, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
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 enrollee was referred for the laboratory services by a contract provider. The file does not show that the 
plan provided notice that the laboratory services would not be covered. Under Medicare rules, this means the 
laboratory services are considered approved by the Plan. Therefore, we decided that the Plan has to pay for the 
laboratory services provided on August 28, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aid services (V5261, V5267) provided on August 20, 
2021. 
 
You asked the Plan to pay for hearing aid services. You say that when you called to verify your benefits with 
the plan, you were told that you did not have hearing aid coverage at all. You were not given correct 
information from the Plan and therefore did not know you could receive covered hearing aids if you followed 
certain rules. The Plan denied your request. The Plan says the provider in this case is not part of the Plan's 
specified routine hearing vendor network; therefore, the hearing aids are denied. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when they are received through the Plans specified routine hearing vendor network.  
 
We looked at the file and the Plan's rules. The provider in this case is not part of the Plans specified hearing 
vendor network. Based on this information, we decided that the Plan's rules for coverage of hearing aid services 
have not been met. Therefore, we decided that the Plan does not have to pay for hearing aid services (V5261, 
V5267) provided on August 20, 2021.  
 
Your complaint about potential misinformation from a Plan representative is not a valid appeal for medical 
coverage. It appears that the Plan may have asked the hearing vendor to review their call logs but may not have reviewed their own customer service logs to locate your call. The health plan is responsible for coordination of 
your benefits covered under your plan. This part of your complaint is a grievance that must be answered by the 
Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography (CT) of the head or brain (70450) 
provided on January 24, 2022. 
 
You asked the Plan to pay for the CT scan. You say that this service was billed appropriately and is supported 
in the record. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) 
Procedure to Procedure (PTP) edit exists between 70496 and 70450. This PTP edit has a modifier indicator of 
1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with 
this PTP code edit. This service was not billed appropriately by Medicare coding regulations. 
 
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, we have confirmed that code 70450 is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for computed tomography (CT) of the head or brain (70450) 
provided on January 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Accu Check Guide test strips. 
 
You asked the Plan to pre-approve Accu Check Guide test strips. 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 follows Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers as long as the enrollee retains access to all medically necessary items (including non-
preferred brands). 
 
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 Accu Check Guide test strips. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found based on the medical 
records provided there is no documentation that the plan's preferred brand (One Touch test strips) would not be 
adequate in meeting the enrollee's medical needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Accu Check Guide test strips have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Accu Check Guide test strips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat sacroiliac joint injection (27096). 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says physical therapy is required before further injections can be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the injection. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no documentation of recent physical therapy or chiropractic therapy. The enrollee had a 
prior injection in December 2021, but there is no documentation of the degree and duration of pain relief. 
Because of this lack of documentation, the request is deemed 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 the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat sacroiliac joint injection (27096).