Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Decphier testing provided on June 26, 2022. 
 
You asked the Plan to pay for the testing services. You say that the testing is payable as billed. The Plan denied 
your request. The Plan says the role of this test remains uncertain. 
 
The Plan must follow Medicare rules. Medicare rules say that Decipher testing is only covered under certain 
medical indications.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the testing services. Our physician reviewer 
found that the enrollee has adenocarcinoma of the prostate. Imaging revealed short axis left external iliac node 
with subtle PMSA expression possibly representing low-grade metastatic disease. The records do not show that 
the Decipher testing provided was indicated for the enrollee's condition. The Decipher testing is not medically 
necessary or indicated in men with metastatic prostate 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 the testing services have not been met. Therefore, we decided that the Plan does 
not have to pay for the Decphier testing provided on June 26, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on July 13, 2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you disagree with the copayment. 
The Plan denied your request. The Plan says this cost sharing was charged 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 $125 
copayment for outpatient diagnostic tests/Medicare-covered diagnostic radiology services.  
 
You have been asked to pay a $125 copayment for an ultrasound. This item/service falls within the outpatient 
diagnostic tests/Medicare-covered diagnostic radiology services 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 an ultrasound provided on July 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and two or more power seating system motors (E2311), a harness (E2313) and an expandable controller 
(E2377). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that you disagree with the denial. The Plan 
denied your request. The Plan says although there are three approved power options on this wheelchair (tilt, 
recline and elevating leg rests), there is not a medical need to control these power options through the joystick. 
 
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. Your upper limb strength and function are adequate for you to be 
able to control the power options using their own switches which are included in the allowance of these power 
options. Based on this information, we decided that Medicare rules for coverage of wheelchair accessories have 
not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic connection 
between wheelchair controller and two or more power seating system motors (E2311), a harness (E2313) and 
an expandable controller (E2377).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the simple extraction (D7140) and two surgical extractions 
(D7210) provided on September 27, 2021. 
 
You asked the Plan to pay for the dental services. You say that this facility was listed in the provider directory, 
and you were told they were in-network. You also say that you do not believe you should be held liable for 
these services. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental benefits. 
 
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 record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the simple extraction (D7140) and two surgical extractions (D7210) provided on September 27, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation  per quadrant (D4921), and drugs or 
medicaments dispensed in the office for home use (D9630) provided on August 11, 2022. 
 
You asked the Plan to pay for the gingival irrigation  per quadrant (D4921), and drugs or medicaments 
dispensed in the office for home use (D9630). You say that you were advised that the provider was in-network.  
 
 You also say that the provider gave you the medication as preventative maintenance to make sure your teeth 
were ready for the work ahead. The Plan denied your request. The Plan says these services are not covered 
under the benefit package. 
 
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 pay for gingival 
irrigation  per quadrant (D4921), and drugs or medicaments dispensed in the office for home use (D9630) 
provided on August 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the comprehensive oral evaluation (D0150) to be 
provided by an endodontist. 
 
You asked the Plan to pre-approve the dental service. You say that you need to save tooth #7 that has a large 
abscess. You say you were referred to go see an endodontist. The Plan denied your request. The Plan says 
dental services from an endodontist are not covered by your supplemental benefits. 
 
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. 
 
You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve the 
comprehensive oral evaluation (D0150) to be provided by an endodontist.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder testing provided on May 26, 2022. 
 
You asked the Plan to pay for the testing services. You say that the testing identifies bladder cancer tumors. 
The Plan denied your request. The Plan says the testing is experimental. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the testing services. Our physician reviewer 
found that the enrollee has recent microscopic hematuria associated with a urinary tract infection. The 
microscopic hematuria has since resolved. CxBladder is not considered a screening test for urothelial cancer. 
Cystoscopy, ureteroscopy, possible biopsy and upper tract imaging will still be necessary regardless of the 
results of CxBladder testing. Urinary biomarker tests such as CxBladder give significant false-negative results 
in patients with urothelial cancer and are subject to false-positive results in others. Accuracy is poor for low-
stage and low-grade tumors. To date, there are multiple urine markers that have improved sensitivity over 
cytology but there is lack of validation of clinical utility. There is insufficient reliable evidence in the peer 
reviewed medical literature to establish the efficacy or effects on health care outcomes. Further prospective 
validations are needed to confirm these findings. The records do not show that the CxBladder testing would 
impact clinical management of the enrollee and was not medically necessary to treat 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 the testing services have not been met. Therefore, we decided that the Plan does 
not have to pay for the CxBladder testing provided on May 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two additional anterior resin-based composites of one 
surface (D2330 x2), two anterior resin-based composites of two surfaces (D2331 x2), and posterior resin-based 
composite of three surfaces (D2393) provided on June 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that you asked if these services would be covered 
and were advised that they would be covered by your insurance. You also say if you had known these services 
would not be covered, you would not have accepted the treatment because you cannot pay for it. 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 June 22, 2022. Therefore, 
we decided that the Plan does not have to pay for the two additional anterior resin-based composites of one 
surface (D2330 x2), two anterior resin-based composites of two surfaces (D2331 x2), and posterior resin-based 
composite of three surfaces (D2393) provided on June 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

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

 
We decided that the Plan does not have to pre-approve a power wheelchair accessory, attendant control, 
proportional, including all related electronics and fixed mounting hardware (E2331). 
 
You asked the Plan to pre-approve a wheelchair accessory. You say that the requested accessories are 
medically necessary. The Plan denied your request. The Plan says the attendant control feature remains denied 
as not medically necessary and non-covered as is it covered in place of a beneficiary-operated drive control 
system if the beneficiary meets coverage criteria for a wheelchair, is unable to operate a manual or power 
wheelchair and has a caregiver who is unable to operate a manual wheelchair but can operate a power 
wheelchair. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
 
 The file shows that you were approved for the group 3 power wheelchair with the upgraded beneficiary-
operated drive control system, expandable controller, electronic connection between 2 or more power seating 
motors, and the harness. Therefore, the attendant control feature remains denied as not medically necessary and 
non-covered. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair accessory, 
attendant control, proportional, including all related electronics and fixed mounting hardware (E2331).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bebtelovimab injection provided on June 10, 2022. 
 
You asked the Plan to pay for a bebtelovimab injection. You say that you were not told you needed a prior 
authorization. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a bebtelovimab injection 
provided on June 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF admission will ensure improvement in the 
enrollee's overall health and function. The Plan denied your request. The Plan says an IRF admission is not 
medically necessary. 
 
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 that the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program.  While the enrollee may need physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
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 an IRF admission and services.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for specimen collection for COVID-19 billed with code G2023 for date of 
service June 17, 2022. 
 
You asked the Plan to pay for procedure code G2023. You say that these services were necessary and were 
reported appropriately. The Plan denied your request. The Plan says that they have agreed to pay for codes 
87581, 87637, 87651 and 87798; however, code G2023 remains denied. G2023 is specimen collection for 
severe acute respiratory syndrome, coronavirus2, any specimen source but is coding specific for a homebound 
patient with collection at the patient's home or when the collection is done at a skilled nursing facility, non-
hospital inpatient setting or a laboratory on behalf of a home health agency. The medical records attached do 
not indicate the collection was completed using any of the above scenarios. 
 
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 G2023 is specimen collection for severe acute respiratory syndrome coronavirus 2 (sars-cov-2) 
(coronavirus disease [covid-19]), any specimen source. 
 
We find that CPT code G2023 is supported in the medical record. Specifically, the scenarios described by the 
Plan in their denial are required for billing code G2024 rather than code G2023. Because the Plan states that the 
scenarios required for billing G2024 have not been met in this case, G2023 is appropriate. Based on this 
information, we decided that Medicare rules for coverage of procedure code G2023 have been met. Therefore, 
we decided that the Plan has to pay for specimen collection for COVID-19 billed with code G2023 for date of 
service June 17, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nail debridement provided on August 18, 2022. 
 
You asked the Plan to pay for nail debridement. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for nail debridement 
provided on August 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care products provided on March 30, 2022. 
 
You asked the Plan to pay for wound care products. You say that these supplies are a separately billable 
expense that does not require separate authorization. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for wound care products 
provided on March 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on July 6, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says Medicare does not 
separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on July 6, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an acute specialist visit provided on August 
10, 2022. 
 
You asked the Plan to waive the copayment for an acute specialist visit. You say that you were unaware you 
had this copayment. The Plan denied your request. The Plan says this cost sharing was charged 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 $10 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $10 copayment for an acute specialist visit. This item/service falls within the 
physician/practitioner services, including doctors office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for an acute specialist visit provided on August 10, 2022.