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

 
We decided that the Plan does not have to pay for an office visit provided on May 1, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that this provider regularly complies with all 
administrative requirements for payments. The Plan denied your request. The Plan says this provider is not a 
network provider with the Plan. The Plan also says that they have also determined that these services are not 
urgent or emergent, nor were they 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 items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on May 1, 2022, by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vacuum-assisted socket system (VASS) system. 
 
You asked the Plan to pre-approve a VASS system. You say that this is medically reasonable for the enrollee's 
condition. The Plan denied your request. The Plan says there are only a few publications in the literature that 
examine the efficacy of the VASS system and studies did not demonstrate that the use of VASS provided 
consistent statistical clinical significance. 
 
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 VASS system. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this request is for a VASS device as part of a leg prosthesis for an enrollee with a transtibial 
amputation. The enrollee currently functions at the K2 level and is reported to have developed blisters on his stump. In this case, Medicare rules say that the system may not exceed the enrollee's needs and must be 
consistent with prevailing practice. There are indeed very few studies supporting the VASS system. One small, 
randomized trial of 20 patients with ulcers on their stumps and another quasi-experimental design with 16 
participants. The system is not the prevailing standard of care, and it is not clear the system is necessary to 
meet the enrollee's 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 a VASS system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a vacuum-assisted socket system (VASS) system.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for chemotherapy drugs provided on March 
18, 2022. 
 
You asked the Plan to waive the coinsurance for chemotherapy drugs. You say that this should be covered 
because this was your third infusion, and everything was pre-approved. The Plan denied your request. The Plan 
says the coinsurance applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare covered Part B drugs.  
 
You have been asked to pay $7, 040 which is 20% of the allowed amount for chemotherapy drugs. The allowed 
amount is $36, 501.47 (20% x $36,501.47= $7,040). Chemotherapy drugs falls within the Medicare Part B 
Prescription Drugs benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for chemotherapy drugs 
provided on March 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services provided on July 7, 2021. 
 
You asked the Plan to pay for the services provided. You say that the guidelines do not require a modifier. The 
Plan denied your request. The Plan says the Medicare rule for payment has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that the pathology services were provided to the enrollee during inpatient care. Based on this 
information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we 
decided that the Plan does not have to pay for the pathology services provided on July 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral for out-of-network continuity of care. 
 You asked the Plan to pre-approve the referral. You say that you need to go back for a follow-up visit. The Plan 
denied your request. The Plan says this provider is out-of-network and you can be redirected to an in-network 
physician. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for 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 pre-approve the referral. Our reviewer says that the 
requested referral is not medically reasonable or necessary. Our physician reviewer found that the review 
indicates that you are not currently receiving any active treatment and/or medical management of your 
condition that makes it medically necessary to continue care with the out-of-network neurosurgery provider as 
requested. There is not anything unique about your condition that would make it medically necessary to 
continue care with out-of-network provider. The plan has shown that they have in-network neurosurgery 
specialists who have the qualifications and expertise necessary to meet the current medical standards of care 
required for this case. Your medical management and/or follow-up care can be safely transitioned to an in-
network neurosurgery specialist at this time. 
 
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 referral have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a referral for out-of-network continuity of care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic paraenteral drugs (D9612) and the collection 
and application of autologous blood concentrate products (D7921). 
 
You asked the Plan to pre-approve the dental services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says therapeutic paraenteral drugs (D9612) and the collection and 
application of autologous blood concentrate products (D7921) are not covered by your routine dental 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. 
 
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 
therapeutic paraenteral drugs (D9612) and the collection and application of autologous blood concentrate 
products (D7921).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite filling (D2391) provided on May 6, 
2022. 
 
You asked the Plan to pay for a filling. You say that you thought this was a covered service. The Plan denied 
your request. The Plan says a resin-based composite filling (D2391) is not covered by your dental 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. 
 
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 a resin-
based composite filling (D2391) provided on May 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified mass spectrometry provided along with drug 
testing on February 21, 2022, billed with code 83789. 
 
You asked the Plan to pay for the services as billed. You say that this drug testing was medically necessary and 
should be paid. The Plan denied your request. The Plan says payment was approved for the drug testing, but no 
separate payment can be made for 83789. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services as billed have not been met. Specifically, we find that the testing described by the 
billed code is considered specimen validity testing which is not separately payable. Therefore, we decided that 
the Plan does not have to pay for the unspecified mass spectrometry provided along with drug testing on 
February 21, 2022, billed with code 83789.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the oral evaluation and x-rays. We decided that the Plan does not 
have to pay for the dental extractions.  
 
You asked the Plan to pay for the dental services. You say that you feel that this should be covered because you 
needed these teeth removed before you could have the heart surgery you needed. The Plan says that this is 
dental care and cannot be covered by the Plan. 
 
 We decided that the Plan has to pay for the oral evaluation and x-rays.  
 
The Plan follows Medicare rules. Medicare rules say that medically necessary services are covered, when they 
are not excluded. Services primarily involving the care, treatment, filling, removal or replacement of teeth or 
structures directly supporting the teeth are excluded services. 
 
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 dental services. Our reviewer says that 
the services at issues are considered medical in nature and were reasonable and necessary. The exam and x-rays 
were not performed primarily for the care/treatment of teeth or supporting structures. Our physician reviewer 
found these services were related to the patient requiring cardiac valve replacement surgery. Treatment of 
current or pending infections related to the teeth is the standard of care for this procedure.  
 
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 dental services have been met. Therefore, we decided that the Plan has to 
pay for the oral evaluation and x-rays.  
 
We also decided that the Plan does not have to pay for the dental extractions. 
 
The Plan follows Medicare rules. Medicare rules say that removal of the teeth is considered a dental service 
which is not covered by Medicare. An exception to this is when a patient has oral cancer and dental extractions 
are needed to administer radiation directly to the tumor.  
 
We find that the extractions provided in this case do not meet the exception to be considered incidental to a 
medical procedure, such as radiation for oral cancer. The extractions were performed due to dental decay. 
Though this was appropriate to reduce risks for planned surgery, it is not considered incidental to that surgery.  
Based on this information, we decided that Medicare rules for coverage of the dental extractions have not been 
met. Therefore, we decided that the Plan does not have to pay for the dental extractions. 
 
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 pre-approve a bone replacement graft. 
 
You asked the Plan to pre-approve a bone replacement graft. You say that the service should be covered. The 
Plan denied your request. The Plan says the service at issue 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 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 a 
bone replacement graft.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and a two 
dimensional oral/facial photographic image (D0350) provided on April 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not aware that these services would 
not be covered. The Plan denied your request. The Plan says your benefit for the comprehensive oral evaluation 
has already been exhausted. A two dimensional oral/facial photographic image 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 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 comprehensive oral evaluation was exhausted on date of service September 24, 
2021. Additionally, a two dimensional oral/facial photographic image is not a covered benefit. Therefore, we 
decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and a two dimensional 
oral/facial photographic image (D0350) provided on April 7, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SNF admission. 
 
You asked the Plan to pre-approve the SNF admission. You say that the enrollee continues to require inpatient 
level of care because she is severely debilitating with functional impairment and is recovering from a 
complicated urinary tract infection with urologic surgical intervention. The Plan denied your request. The Plan 
says based on Medicare guidelines and your request for approval of admission to a skilled nursing facility does 
not meet the requirements for approval. 
 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 SNF admission. Our reviewer says 
that there are no identifiable skilled nursing service needs. Our physician reviewer found the enrollee has a 
history of urinary tract infection and hydronephrosis. The enrollee received oral medications and had stable 
signs. The enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and 
judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the 
specialized skill, knowledge, and judgment of a skilled professional therapist. Our reviewer also found that the 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
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 SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the SNF admission.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne testing provided on May 10, 2021. 
 
You asked the Plan to pay for the testing services. You say that the test is approved for use as a companion 
diagnostic. The Plan denied your request. The Plan says the documentation does not support the testing. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that the claim at issue was not billed with the appropriate DEX Z-code identifier. 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 FoundationOne testing provided on May 10, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
November 23, 2021, to December 21, 2021. 
 
You asked the Plan to pay for home health services. You say that the RAP was filed on November 29, 2021. 
The Plan denied your request. The Plan says the RAP was not filed within 5 days. 
 
The Plan must follow Medicare rules. The rules say that for calendar year 2021, all Home Health Agencies 
(HHAs) must submit a request for anticipated payment (RAP), which is to be paid at 0 percent, within 5 
calendar days after the start of care and within 5 calendar days after the from date for each subsequent 30-day 
period of care. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, a RAP was 
not submitted within 5 days of the start of care. Therefore, we decided that the Plan does not have to pay for the 
home health services provided to the enrollee from November 23, 2021, to December 21, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a COVID-19 at-home test kit provided on March 10, 2022. 
 
You asked the Plan to pay for a COVID-19 at-home test kit. You say that COVID-19 was just as prevalent and 
virulent on March 10, 2022 as it was on April 4, 2022. The Plan denied your request. The Plan says Medicare 
does not reimburse for OTC Covid-19 tests prior to April 4, 2022. In addition, the member did not contact the 
Plan to utilize the Over-the Counter mail order quarterly benefit to purchase the COVID test and it was not 
ordered by a physician. 
 
The Plan must follow Medicare rules.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a COVID-19 at-home test kit have not been met. Therefore, we decided that the Plan does not have 
to pay for a COVID-19 at-home test kit provided on March 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hip orthoses (L1686, L2624) provided on February 3, 
2022. 
 
You asked the Plan to pay for the hip orthoses. You say that this equipment was medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says they have confirmed that the provider did not 
order the equipment in question. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. In this case, the documentation does not provide evidence that the provider discussed the medical 
need for the hip orthoses with the enrollee. The medical records submitted do not include any reference to the 
ordered equipment. Therefore, we decided that the Plan does not have to pay for the hip orthoses (L1686, 
L2624) provided on February 3, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93010 billed for date of service January 18, 
2022. 
 You asked the Plan to pay for procedure code 93010. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says payment for code 93010 is bundled into 
payment for code 92950. 
 
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 93010 
is a column II code to column I code 92950. 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 93010 billed for date of service January 18, 
2022.