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

 
We decided that the Plan does not have to pay for knee replacement surgery and other medical services 
provided in the Republic of India from February 8, 2023, to May 1, 2023. 
 
You asked the Plan to pay for medical services. You say that these services should be paid for. The Plan denied 
your request. The Plan says the services were not emergent or urgent in nature. 
 
The Plan follows Medicare rules. Medicare rules state that items and services furnished outside of the United 
States are generally not covered, except in limited specified circumstances. The Plan has a worldwide coverage 
benefit that goes beyond Medicares coverage. For that reason, the Plans rules apply to this case. The Plan 
covers worldwide emergency care, urgently needed care, and emergency ambulance transportation from the 
scene of an emergency to the nearest medical treatment facility. 
 
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 medical services. Our reviewer says that 
these services do not meet criteria for payment. Our physician reviewer found you have right knee 
osteoarthritis and were treated with a knee replacement surgery and other services while in India. The 
emergency department visit when you reported knee pain was approved by the Plan; however, the surgery and 
related care is not sufficiently supported as they were not emergent in nature. You could have foreseen 
requiring knee replacement prior to leaving the United States. The records do not indicate that the care 
provided was medically necessary at that time and with those providers. It would have been reasonable to delay 
care until you returned to your Plan service area. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of medical services have not been met. Therefore, we decided that the Plan does 
not have to pay for knee replacement surgery and other medical services provided in the Republic of India from 
February 8, 2023, to May 1, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the general health panel (80050) provided on March 15, 
2023. 
 
You asked the Plan to pay for the general health panel. You say that you blood work has always been covered. 
The Plan denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is considered a non-
covered code. 
 
You have requested payment for services billed under code 80050. Medicare does not cover or pay for services 
billed under this code. Therefore, we decided that the Plan does not have to pay for the general health panel 
(80050) provided on March 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the pneumatic compression device (E0651, E0667) to 
be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the pneumatic compression device. You say that the item should be covered. 
The Plan denied your request. The Plan says there are in-network providers available that can provide this item. 
 
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 
the pneumatic compression device (E0651, E0667) to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have waive the copayment for the CT of the abdomen provided on 
December 3, 2021. 
 
You asked the Plan waive the copayment for a CT scan of the abdomen. You say that you have never had to 
pay this type of cost sharing before and you do not feel you should be responsible to pay this. 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 $300 
copayment for CT scan.  
 
You have been asked to pay $247.97 for a CT scan of the abdomen. This amount is less than the standard $300 
copayment. This item/service falls within the CT scan 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 waive the 
copayment for CT of the abdomen provided on December 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 24, 2023, billed with 
codes 87481, 87640, 87651, 87653, and 87798. 
 
You asked the Plan to pay for the genetic testing billed. You say that the documentation shows medical 
necessity of the units billed. The Plan denied your request. The Plan says panel testing should be billed using 
one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. The file shows that a wound panel was provided. We looked at the file and Medicare rules. This NGS panel 
was not billed with a single code as required. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing 
provided on July 24, 2023, billed with codes 87481, 87640, 87651, 87653, and 87798.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lokelma. 
 
You asked the Plan to pre-approve the medication. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the medication is not covered as a medical 
benefit under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Lokelma.  
 
Benefits for the medication 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99153 billed for date of service May 7, 2023. 
 
You asked the Plan to pay for procedure code 99153. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says this code is not separately payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while an inpatient. Per the Physician Fee 
Schedule, there is a Professional/Technical indicator of 3 for CPT code 99153. This means there is only a 
technical component for the CPT code. In this case, CPT code 99153 may not be paid if furnished to hospital 
inpatients. Based on this information, we decided that Medicare rules for coverage of procedure code 99153 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99153 billed 
for date of service May 7, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health occupational therapy (G0152 x10). 
 You asked the Plan to pre-approve home health services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care 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 pre-approve home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee is 
able to progress with a repetitive exercise program. Unique input from a skilled therapist is not 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health occupational therapy (G0152 x10).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with codes 87481, 87640, 
87653, and 87798 for date of service July 31, 2023.  

You asked the Plan to pay for the laboratory services billed with codes 87481, 87640, 87653, and 87798. You 
say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the services are not 
payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the amplified probe 
technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were used in 
this case. As such, a single code with one unit of service should be used. Based on this information, we decided 
that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory services billed with codes 87481, 87640, 87653, and 87798 for date of 
service July 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the determination of refractive state (92015) and waive the 
cost share for the diagnostic imaging provided on July 31, 2023. 
 
You asked the Plan to pay for the determination of refractive state and waive the cost share for the diagnostic 
imaging. You say that this was an annual eye check-up that you get once a year. The Plan denied your request. 
The Plan says refractive procedures are not a covered benefit. The Plan also says that the $5 copayment was 
applied correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear. 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 $5 copayment for each specialists office visit.  
 
The services you asked the Plan to pay for are considered routine vision services or eyewear. Additionally, you 
have been asked to pay a $5 copayment for the diagnostic imaging. This service falls within the vision 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 pay for the determination of refractive state (92015) and 
waive the cost share for the diagnostic imaging provided on July 31, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entyvio. 
 You asked the Plan to pre-approve the drug. The Plan denied your request. The Plan says that the step therapy 
requirements 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 the drug. Our reviewer says that 
Entyvio is not medically necessary. Our physician reviewer found that the enrollee has not tried and failed the 
Plan's required drugs Remicade, Inflectra, infliximab and Stelara. Also, there is no indication that the Plan's 
required drugs would likely be less effective 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 the drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Entyvio.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for an outpatient surgery provided on June 23, 
2023. 
 
You asked the Plan to waive the cost share for an outpatient surgery. You say that you disagree with the cost 
share. 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. Your 
contract with the Plan says that there is a $1000 deductible which applies to outpatient surgery.  
 
The item or service you asked the Plan to waive the cost share for falls within the outpatient surgery benefit 
category. You are being asked to pay $131.35 towards your $1,000 deductible. The Plan has followed 
Medicare rules by clearly disclosing in the contract that there is a $1000 deductible which applies to outpatient 
surgery. This cost sharing is a contractual obligation that had not been met at the time an outpatient surgery 
was received on June 23, 2023. Therefore, we decided that the Plan does not have to waive the cost share for an 
outpatient surgery provided on June 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic for tooth #26 and retainer crown for tooth #27 
(D6740, D6245). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. 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 August 30, 2023, with the Plan's 
authorization of 4 other implants under authorization #A0230829170186. Therefore, we decided that the Plan 
does not have to pre-approve a pontic for tooth #26 and retainer crown for tooth #27 (D6740, D6245).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided on March 14, 2023, 
to March 24, 2023, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
enrollee met the criteria for the diagnosis. The Plan denied your request. The Plan says sufficient 
documentation to validate the diagnosis was not found.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services with diagnosis code J96.01, defined as acute respiratory failure 
with hypoxia. 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 inpatient hospital 
services at the DRG originally billed. Our physician reviewer found that the enrollee was hospitalized with a 
fractured hip. This exacerbated chronic cardiac issues, which were managed by cardiology. There is no 
evidence that the enrollee had respiratory failure. As such, the billing of J96.01 is not supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital services provided on March 14, 2023, to March 24, 2023, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids provided on August 10, 2023. 
 
You asked the Plan to pay for the hearing aids. You say that you have had hearing loss from childhood, and 
you need to see this audiologist. You say this provider has the specific equipment you require. The Plan denied 
your request. The Plan says the service is not a covered benefit. 
 
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 received through the Plan's hearing network.  
 
We looked at the file and the Plan's rules. Specifically, the hearing aids were received by an out-of-network 
provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not 
been met. Therefore, we decided that the Plan does not have to pay for the hearing aids provided on August 10, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and fundus photography with interpretation 
and report provided on December 7, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the specialist services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 the office visit and fundus photography with 
interpretation and report provided on December 7, 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 compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that the items should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the items denied correctly as they are 
excluded from Medicare. 
 The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6549.