Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the CPAP supplies provided by an in-
network provider on September 8, 2023. 
 
You asked the Plan to waive the deductible for the CPAP supplies. You say that you were told that you would 
only have to pay the coinsurance. 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 $500 deductible which applies to in-network durable medical 
equipment (DME) and related supplies.  
 
 
 
 
 You have been asked to pay a $228.59 deductible for the CPAP supplies. The items or services you asked the 
Plan to waive the deductible for fall within the durable medical equipment (DME) and related supplies benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 
deductible which applies to durable medical equipment (DME) and related supplies. This cost sharing is a 
contractual obligation that had not been met at the time the CPAP supplies were received on September 8, 
2023. Therefore, we decided that the Plan does not have to waive the deductible for the CPAP supplies 
provided by an in-network provider on September 8, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lower extremity prostheses and flex-walk system or 
equal and multi-axial rotation unit (L5981, L5986). 
 
You asked the Plan to pre-approve the prostheses. You say that the items should be covered as the enrollee 
disagrees with the denial. The Plan denied your request. The Plan says the items denied correctly as the 
enrollee does not meet the clinical requirements to be approved. 
 
The Plan follows Medicare rules. Medicare rules say that for any durable medical equipment, prosthetics, 
orthotics and supplies (DMEPOS) item to be covered by Medicare, the patient's medical record must contain 
sufficient documentation of the patient's medical condition to substantiate the necessity for the type and 
quantity of items ordered and for the frequency of use or replacement (if applicable). 
 
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 prostheses. Our physician reviewer 
found that the treating provider's documentation do not provide justification for functional level or 
corroborating prosthetist notes for K3 functional level. For this reason, medically necessity cannot sufficiently 
be determined. 
 
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 prostheses have not been met. Therefore, we decided that the Plan does not 
have to pre-approve lower extremity prostheses and flex-walk system or equal and multi-axial rotation unit 
(L5981, L5986).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC gene expression test rendered on 
August 9, 2023. 
 
You asked the Plan to pay for the test. You say that this is medically necessary. The Plan denied your request. 
The Plan says the DEXTM Diagnostics Exchange Registry documents the DecisionDx-SCC testing has been 
evaluated by the MolDX Program and is considered non-covered at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that MolDX will reimburse approved tests covered 
for dates of service consistent with the effective date of the coverage determination. 
 
The DEX Registry non-covers the DecisionDX-SCC test at this time. Based on this information, we decided 
that Medicare rules for coverage of the test have not been met. Therefore, we decided that the Plan does not 
have to pay for the DecisionDx-SCC gene expression test rendered on August 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chronic care management services provided on 
September 14, 2023. 
 
You asked the Plan to pay for the chronic care management services. You say that you are requesting 
reconsideration of the denied claim. 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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 the chronic care management services provided on September 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation and extraction (D0150, 
D7140) provided on November 9, 2022, to November 23, 2022. 
 
You asked the Plan to pay for 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 comprehensive oral evaluations 
has already been exhausted. Coverage for the extractions denied correctly as they do not fall within 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, certain limitations apply. The record 
shows your benefit for comprehensive oral evaluation was exhausted on date of service September 21, 2022 
(D0150). Coverage for the extractions denied correctly as they do not fall within your dental benefits. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation or extraction 
(D0150, D7140) provided on November 9, 2022, to November 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee orthosis (L1852, L2397) provided on September 5, 
2023. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the records do not show a diagnosis of knee arthritis. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the documentation does not reveal evidence of objective joint laxity or instability of the knees on a 
physical examination. There is no evidence of a recent injury or surgery to the knees. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for a knee orthosis (L1852, L2397) provided on September 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an alveoloplasty in junction with extractions (D7310), and 
extractions (D7210) provided on August 7, 2023, to August 10, 2023. 
 
You asked the Plan to pay for the dental services. You say that you feel like the Plan should pay more. The 
Plan denied your request. The Plan says your annual dental allowance amount 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 annual dental allowance amount was exhausted on date of service May 4, 2023. Therefore, we 
decided that the Plan does not have to pay for an alveoloplasty in junction with extractions (D7310), and 
extractions (D7210) provided on August 7, 2023, to August 10, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit (99285) provided on 
February 26, 2023. 
 
You asked the Plan to pay for an emergency department visit (99285). You say that procedure code 99285 is 
appropriate based on the services performed. The Plan denied your request. The Plan says the records do not 
support the services at issue in this case. 
 
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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 
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 an emergency department visit (99285). Our reviewer says 
that the service at issue in this case is not supported by the medical records. Our reviewer found the enrollee 
was evaluated in the emergency department (ED) for chest pain following a recent cardiac catheterization. The 
documentation supports an appropriate history and physical were documented. A standard cardiac evaluation 
was conducted, and the patient was discharged; Therefore, the medical decision making was not of high 
complexity and the billing of CPT 99285 is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an emergency department visit (99285) have not been met. Therefore, we 
decided that the Plan does not have to pay for an emergency department visit (99285) provided on February 26, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDX-Melanoma test (81529) provided on April 
19, 2023.  
You asked the Plan to pay for the DecisionDX-Melanoma test. You say that criteria for coverage are not met. 
The Plan denied your request. The Plan says this test was ordered by the enrollee's treating physician with the 
intent to use test results to inform treatment decisions. 
 
The Plan follows Medicare rules. Medicare rules say that this test is covered when the presumed risk for a 
positive SLNB based on clinical, histological, or other information in greater than 5%. 
 
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 DecisionDX-Melanoma test. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found that the DecisionDx 
test was performed after the sentinel node biopsy which was negative for lymph node involvement. Given the 
sequence of DecisionDx use after the wide local excision and sentinel node biopsy, this does not meet the LCD 
criteria. 
 
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 DecisionDX-Melanoma test have not been met. Therefore, we decided that 
the Plan does not have to pay for the DecisionDX-Melanoma test (81529) provided on April 19, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity (J3111). 
 You asked the Plan to pre-approve Evenity. You say that the patient cannot be treated with Forteo, and you 
would like Evenity to be considered for their treatment. The Plan denied your request. The Plan says the patient 
does not have any stated contraindications to the preferred products. The patient has not tried any of the 
preferred agents. The Plan also says a rationale was not provided for use of the non-preferred product for safety 
or efficacy. 
 
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 Evenity. Our reviewer says that the 
patient does not meet the criteria for coverage. Our physician reviewer found the provided records do not 
indicate that the patient has tried and failed the Plan's preferred step one alternative. The record does not 
indicate that the patient has a contraindication to, or would have an adverse effect from the Plan's preferred step 
one alternative. Our reviewer found that the elements of the coverage criteria are not satisfied. Our physician 
reviewer also found that the requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity (J3111).
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 you say you prefer to be admitted to acute 
rehabilitation because you were independent and active before coming to the hospital and wish to return to 
being independent as quickly as possible. The Plan denied your request. The Plan says that admission to an IRF 
is not medically necessary and does not meet the criteria for coverage.  
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for periorbital cellulitis. There are no complex nursing or rehabilitation needs. The enrollee does 
not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to hold you harmless for physical therapy services (97161) provided on 
September 5, 2023. 
 
You asked the Plan to hold you harmless for physical therapy services. You say that you were told this was an 
in-network facility, and you should not be responsible for miscoded services. The Plan denied your request. 
The Plan says that there is an approved authorization on file for these services; however, the procedure code 
billed for this service does not match what is listed on the authorization. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that the Plan did not provide a copy of the relevant authorization for 
review. Without this document, we cannot verify whether or not the code billed matches what was pre-
approved. In addition, the services billed should accurately reflect the care provided, and this may on occasion 
mean that the exact procedure codes billed do not match what is listed on an authorization. Further, if a code 
was billed in error, the billing error is not the responsibility of the enrollee. The Plan has not substantiated their 
denial in this case. Therefore, we decided that the Plan has to hold you harmless for physical therapy services 
(97161) provided on September 5, 2023.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a 100-day supply of FreeStyle Lite Test Strips (A4253). 
 
You asked the Plan to pre-approve a 100-day supply of FreeStyle Lite Test Strips. The Plan denied your 
request. The Plan says the requested amount is not reasonable and necessary. 
 
The Plan follows Medicare rules. Medicare rules say that the quantity of test strips (code A4253) that are 
covered depends on the usual medical needs of the beneficiary and whether or not the beneficiary is being 
treated with insulin, regardless of their diagnostic classification as having Type 1 or Type 2 diabetes mellitus. 
 
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 100 day supply of FreeStyle Lite Test 
Strips. Our physician reviewer found the requested item is available as a recurring 90-day supply. This testing 
item has already been approved (under a separate determination) as a recurring 90-day supply of 450 strips 
(enough to test up to 5 times per day) through December 31, 2024. Our reviewer found that the review has 
determined that the Plans denial of a 100-day supply of the FreeStyle Lite Test Strips (A4253) is appropriate. 
Our physician reviewer also found that the criteria for coverage of the requested quantity has not been met. 
 
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 100-day supply of FreeStyle Lite Test Strips have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a 100-day supply of FreeStyle Lite Test Strips (A4253).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration of denied 
authorization. The Plan denied your request. The Plan says the coverage criteria has not been met. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the complexity of the enrollee's nursing, medical, and rehabilitation needs do require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. She would benefit from the oversight of 
a rehabilitation physician and rehabilitation nursing given the complexity of her electrolyte abnormalities and 
seizure disorder. The enrollee does require treatment by multiple therapies, including either physical therapy or 
occupational therapy in an intensive rehabilitation therapy program. The enrollee has had a decline from her 
baseline level of function and will benefit from the intensity of therapies provided in an acute inpatient 
rehabilitation. Therefore, an acute inpatient rehabilitation admission is 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 IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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.