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

 
We decided that the Plan does not have to pay for out of network services provided to the enrollee on 
September 30, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The 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 out of network services provided to the enrollee on 
September 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of a spinal cord stimulator. 
 
You asked the Plan to pre-approve implantation of a spinal cord stimulator. You say that this is medically 
reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage have not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that the implantation of the stimulator is used only as 
a late resort. 
 
 We looked at the file and Medicare rules. In this case, the most recent documentation shows your pain has 
improved. This spinal cord stimulator would not be considered a last resort option at this time. Based on this 
information, we decided that Medicare rules for coverage of implantation of a spinal cord stimulator have not 
been met. Therefore, we decided that the Plan does not have to pre-approve implantation of a spinal cord 
stimulator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network services provided to the enrollee on 
November 11, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 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 out of network services provided to the enrollee on 
November 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray exam of the spine (72070) provided on October 20, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an x-ray exam of the spine. You say that no one told you the follow-up care 
would not be in-network, nor was that explicitly stated on the paperwork. The Plan denied your request. The 
Plan says the services were denied because the provider is out-of-network. The Plan also says that a prior 
authorization is required if you are seeking non-emergency, out-of-network care, and no prior authorization 
was requested. 
 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 x-ray exam of the spine (72070) provided on 
October 20, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transthoracic echocardiogram (TTE) to be provided by 
an out-of-network (OON) provider. 
 
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 available from network providers. 
 
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 
a transthoracic echocardiogram (TTE) to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya. 
 
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 step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria.  The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has plaque psoriasis. He 
has not tried and failed the Plan's required drugs, Remicade, Inflectra or Infliximab, and Stelara. The records do 
not show that the required drugs would be contraindicated or less effective; therefore, the Ilumya is 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 Ilumya.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 8, 2021. 
 
You asked the Plan to pay for the lab services. You say that you have provided documentation to support 
payment for these services. The Plan denied your request. The Plan says these lab services were billed with the 
wrong Place of Service (POS) code. 
 
The Plan must follow Medicare rules. Medicare rules say that that if an independent lab bills for services, the 
place where the sample was taken is reported as the Place of Service (POS). An independent laboratory taking a sample in its laboratory shows "81" as place of service.  In this case, it appears as though your lab did not 
take the sample directly from the patient in your facility.  Rather, the patient's sample was sent to you from 
another facility.  The location where the sample is physically taken from the patient is the POS code that should 
be reported on the claim. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab 
services provided on June 8, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility services. 
 
You asked the Plan to pre-approve the skilled nursing facility services. You say that the SNF services are 
medically necessary. The Plan denied your request. The Plan says 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 the skilled nursing facility services. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found the record shows that 
the beneficiary does not require skilled nursing or therapy services on a daily 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 skilled nursing facility services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve skilled nursing facility services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a multiaxial ankle represented by code L5968 and a 
flexible keel foot represented by code L5972. 
 
You asked the Plan to pre-approve codes L5968 and L5972. You say that the records provided support the 
medical necessity of the items in dispute. The Plan denied your request. The Plan says the enrollee's notes do 
not support that the enrollee is a K2 ambulator. 
 
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 codes L5968 and L5972. Our reviewer 
says that the requested items are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation from the physical therapy notes does not support that this enrollee is a K2 
ambulator which is a limited community ambulator. The enrollee needs assist of 2 for sliding board transfers 
and has endurance deficits. The enrollee can tolerate wearing the prosthesis for 2 hours daily. The requested 
items exceed the enrollee's medical need. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes L5968 and L5972 have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a multiaxial ankle represented by code L5968 and a flexible keel foot represented 
by code L5972.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the molecular pathology services rendered on June 24, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the submitted records do not support the billing of codes 81401, 81403, 81404, 81405 
and 81406. 
 
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 81401 is molecular pathology procedure level 2. The 
definition of code 81403 is molecular pathology procedure level 4. The definition of code 81404 is molecular 
pathology procedure level 5. The definition of code 81405 molecular pathology procedure level 6. The 
definition of code 81406 is molecular pathology procedure level 7. 
 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 these services. Our reviewer says that the submitted records 
do not support the billing of codes 81401, 81403, 81404, 81405 and 81406. Our reviewer found the submitted 
documentation does not include enough information to confirm that the Medicare criteria for molecular 
pathology procedures are met. The handwritten documentation is illegible and no diagnosis for the tests 
ordered was found. 
 
We looked at this coder'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 pay for the molecular pathology services rendered on June 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor 
 
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results and have had an in-person visit with their treating physician to assesses 
adherence to their CGM regimen and diabetes treatment plan. 
 
  
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections, require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of the monitor 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose 
monitor
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and intraoral 
radiographic imaging (D0210) provided by a participating provider on October 11, 2021. 
 
You asked the Plan to pay for a comprehensive oral evaluation and intraoral radiographic imaging. You say 
that you believe that the Plan should pay for this. The Plan denied your request. The Plan says the benefit limit 
for D0150 and D0210 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. The Plan covers one 
comprehensive oral evaluation every three years, and one intraoral radiographic imaging every five years. 
 
We looked at the file and Medicare rules. Evidence was provided to show that D0150 and D0210 was provided 
on May 15, 2019.  Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation and 
intraoral radiographic imaging have already been met. Therefore, we decided that the Plan does not have to pay 
for a comprehensive oral evaluation (D0150), and intraoral radiographic imaging (D0210) provided by a 
participating provider on October 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941) provided 
October 6, 2021 to November 3, 2021. 
 
You asked the Plan to pay for the chiropractic serviced. You say that the one thing that Medicare can pay for to 
help you stay away from opiates and surgery is being denied and you already have to pay out of pocket for 
several other services. The Plan denied your request. The Plan says the requested services does not meet 
Medicare criteria for medical necessity. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care.  
 
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 the chiropractic serviced. Our reviewer says 
that the enrollee does not meet the Medicare criteria for chiropractic coverage. Our physician reviewer found 
the documentation supports that the enrollee has been put on maintenance 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 the chiropractic serviced have not been met. Therefore, we decided that the Plan 
does not have to pay for the chiropractic manipulative treatment (98941) provided October 6, 2021 to 
November 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the recement or rebond of an implant supported crown 
(D6092), occlusal guard (D9944), and filling (D2302) provided on September 20, 2021. 
 
You asked the Plan to pay for the dental services. You say that the plan's website does not indicate that out of 
network services are not covered. The Plan denied your request. The Plan says dental services that you receive 
out of network are not covered. 
 
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 and filling is listed as covered, dental 
services received out of network are not covered. 
 Additionally, the recement or rebond of an implant supported crown and occlusal guard are not among those 
covered under this benefit, regardless of the provider's network status. Therefore, we decided that the Plan does 
not have to pay for the recement or rebond of an implant supported crown (D6092), occlusal guard (D9944), 
and filling (D2302) provided on September 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76776-26 billed for date of service October 
11, 2021. 
 You asked the Plan to pay for procedure code 76776-26. You say that this code was denied as a duplicate in 
error. The Plan denied your request. The Plan says this code is bundled with another code billed on the same 
date. 
 
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 
76776-26 is a column II code to column I code 93975. 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 procedure code 76776-26 billed for date of service 
October 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for tissue debridement procedure provided on 
November 5, 2021. 
 
You asked the Plan to waive the deductible for surgical service. You say that you did not think this was any 
different than a regular office visit. The Plan denied your request. The Plan says the deductible amount you are 
being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $750 deductible which applies to surgical service provided during a 
doctors office visit. At the time this claim was processed, $510.37 of the $750 deductible had been met. The 
allowed amount of the claim is $127.08, resulting in a deductible amount of $127.08. 
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category 
Physician/Practitioner Services, Including Doctor's Office Visits. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is $750 deductible which applies to Physician/Practitioner Services, 
Including Doctor's Office Visits. This cost sharing is a contractual obligation that had not been met at the time 
surgical service was received on November 5, 2021. Therefore, we decided that the Plan does not have to 
waive the deductible for tissue debridement procedure provided on November 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical placement of implant body: endosteal implant 
(D6010) provided on September 28, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the endosteal implant. You say that you were told that the treating provider 
would be approved because he was the only dentist in the area that could provide this service. You also say that 
the treating provider was approved for 2022 and you were hoping that this service provided in September 2021 
would be approved for payment. The Plan denied your request. The Plan says this service was rendered by an 
OON provider. The Plan also says that you were not advised that this treating provider was a participating 
provider in 2021. 
 
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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the surgical 
placement of implant body: endosteal implant (D6010) provided on September 28, 2021 by an out-of-network 
(OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ocrevus. 
 
You asked the Plan to pre-approve Ocrevus. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says step therapy criteria have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Ocrevus. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found the Plan requires a 
trial of Kesimpta before they will approve the requested drug. In this case, the patient has 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 the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ocrevus have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Ocrevus.