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

 
We decided that the Plan does not have to pay for the panel testing provided on October 21, 2022. 
 
You asked the Plan to pay for the panel testing. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components regardless of the fact that the test reports multiple individual pathogens and/or 
targets. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the panel testing have not been met. Specifically, the service at issue is a test panel which was unbundled and billed as individual components. Therefore, we decided that the Plan does not have to pay for 
the panel testing provided on October 21, 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 December 23, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. 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 
December 23, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0283 provided on January 27, 2022. 
 
You asked the Plan to pay for procedure code G0283. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that outpatient rehabilitation claims must include one of 
the GN, GO, or GP modifiers. 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with one of the required 
GN, GO, or GP modifiers. 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 procedure code G0283 
provided on January 27, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea. 
 
You asked the Plan to pre-approve Eylea. You say that the requested Eylea is medically necessary. The Plan 
denied your request. The Plan says the enrollee must try and fail Avastin first. 
 
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 Eylea. Our reviewer says that the Plan's 
step therapy criteria have not been met. Our physician reviewer found the record indicates that the enrollee has 
Exudative age-related macular degeneration. The requested medication is a new start. The provided records do 
not indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record does not 
indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's preferred 
step one alternative. The elements of the coverage criteria are not satisfied. 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 Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Testopel (J3490). 
 
You asked the Plan to pre-approve Testopel. The Plan denied your request. The Plan says the enrollee does not 
meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
 
  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 Testopel. Our reviewer says that 
Testopel is not medically reasonable and necessary for the enrollee. Our physician reviewer found Testopel 
(J3490) is FDA-approved for the treatment of male hypogonadism, but confirmation of the diagnosis by 
measuring serum testosterone concentrations in the morning on at least 2 separate days is required. Provided 
records in this case do not document confirmation of the diagnosis by measuring serum testosterone 
concentrations in the morning on at least 2 separate days. Our reviewer found in addition, the safety and 
efficacy of testosterone therapy have not been established in men with late-onset (age-related) hypogonadism. 
Our physician reviewer also found that the use of Testopel (J3490) is not supported by one of the major drug 
compendia or by clinical research that appears in a CMS-approved medical journal, and is not indicated, 
supported, or recommended in any of the compendia without adequate diagnosis by measuring serum 
testosterone concentrations in the morning on at least 2 separate days. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Testopel have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Testopel (J3490).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services billed for dates of service from 
November 15, 2022, to December 17, 2022. 
 
You asked the Plan to pay for home health services. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says rules for payment for home health services have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the 30-day period of care is the unit of payment 
for the HH PPS. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Specifically, the claim at issue is for a period of care greater than 30 days. Therefore, we decided that the Plan does not have to pay for home health services billed 
for dates of service from November 15, 2022, to December 17, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH placement would be beneficial 
given the enrollee's good progress and expected recovery that is expected to require longer than 25 days in a 
long-term acute care setting. The Plan denied your request. The Plan says the enrollee can safely receive the 
services needed in their current hospital setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
 
 
 
 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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. All medically necessary care is being provided in the 
current acute care 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Bone Marrow Aspirate (20939) and OsteoCell 
Allograft (20930). 
 
You asked the Plan to pre-approve the Bone Marrow Aspirate and OsteoCell Allograft. You say that the 
services are medically necessary. The Plan denied your request. The Plan says the services are not medically 
necessary. 
 
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 the Bone Marrow Aspirate and 
OsteoCell Allograft. Our reviewer says that the requested services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found this particular grafting product does not currently have 
sufficient evidence available showing it superior or equal to standard allograft products used in similar surgeries. Therefore, this request for Bone Marrow Aspirate and OsteoCell Allograft will be considered not 
medically necessary 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 Bone Marrow Aspirate and OsteoCell Allograft have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the Bone Marrow Aspirate (20939) and 
OsteoCell Allograft (20930).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that the requested Prolia is medically necessary. The Plan 
denied your request. The Plan says the enrollee must try and fail zoledronic acid first. 
 
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 Prolia. Our reviewer says that the Plan's 
step therapy criteria have not been met. Our physician reviewer found the enrollee has not had trial and failure 
of zoledronic acid. The documentation does not support that zoledronic acid would likely be less effective, 
and/or would likely have adverse effects for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary for the 
enrollee to regain maximum function. The Plan denied your request. The Plan says the enrollee can stay in the 
hospital until they are safe for transfer or discharge. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. All medically necessary care is being provided in the 
current acute care 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an eXciteOSA starter kit. 
 
You asked the Plan to pre-approve an eXciteOSA starter kit. The Plan denied your request. The Plan says this 
item is considered experimental or investigational for the treatment of obstructive sleep apnea. The Plan also 
says the evidence is insufficient to determine the effects of the technology on health outcomes. 
 
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 an eXciteOSA starter kit. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the eXciteOSA device is not medically necessary because Medicare criteria are not 
met. This is an oral device that provides electrical stimulation to the tongue during the daytime as treatment for 
obstructive sleep apnea (OSA). Our reviewer found that it is intended for mild OSA. It is not intended for 
patients who have OSA with an apnea-hypopnea index (AHI) of 15 and higher. Our physician reviewer found 
that this enrollee's AHI was 22. Our reviewer also found that this device is considered investigational because 
there have not been adequate controlled studies to establish its safety and effectiveness in the treatment of 
OSA. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an eXciteOSA starter kit have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an eXciteOSA starter kit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom abutment (D6057) and a crown (D6058). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. 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. Therefore, we decided that the Plan does 
not have to pre-approve custom abutment (D6057) and a crown (D6058).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that you have serious swelling in your 
legs which require the compression stockings. The Plan denied your request. The Plan says you do not have a 
qualifying wound for coverage of compression stockings. 
 The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 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 A6530.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each emergency room service provided on 
January 27, 2023, to February 03, 2023. 
 
You asked the Plan to waive the copayment for each emergency room service. You say that you had no choice 
but to go to the emergency room. 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 $90 
copayment for emergency care. 
 
You have been asked to pay a $90 copayment for each emergency room service. This item/service falls within 
the emergency care 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. The total amount you owe is $270 ($90 copayment x 3 visits = $270). Therefore, we decided that 
the Plan does not have to waive the copayment for each emergency room service provided on January 27, 
2023, to February 03, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the extraction, erupted tooth requiring removal of bone 
and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210), and a limited 
oral evaluation - problem focused (D0140) provided on June 27, 2022, and July 1, 2022.  We also decided that  the Plan does not have to pay for the guided tissue regeneration  non-resorbable barrier, 
per site (includes membrane removal) (D4267), bone replacement graft for ridge preservation - per site 
(D7953), and cone beam CT capture and interpretation with field of view of one full dental arch  maxilla, with 
or without cranium (D0366) provided on June 27, 2022, and July 1, 2022. 
 
You asked the Plan to pay more for the dental services represented by codes D7210 and D0140, and to pay for 
the guided tissue regeneration  non-resorbable barrier, per site (includes membrane removal) (D4267), bone 
replacement graft for ridge preservation - per site (D7953), and cone beam CT capture and interpretation with 
field of view of one full dental arch  maxilla, with or without cranium (D0366). You say that you believe a 
tomography capture is really a form of x-ray and you would expect at least that amount to be paid. You also 
say that the insertion of a barrier and bone graft replacement on the same date was done to fill a hole in the gum 
where the tooth was removed that led to sinus issues and this was a medical reason not cosmetic. The Plan 
denied your request. The Plan says you are responsible for any charged amount above the Plans cost-sharing 
amount when your services are received from an out-of-network provider. The Plan also says the dental benefit 
only covers procedures included in the Plans dental benefits chart. 
 
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 have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 more for an extraction, erupted tooth requiring 
removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210), 
and a limited oral evaluation - problem focused (D0140) provided on June 27, 2022, and July 1, 2022.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among 
those covered under this benefit . Therefore, we also decided that the Plan does not have to pay for the guided 
tissue regeneration  non-resorbable barrier, per site (includes membrane removal) (D4267), bone replacement 
graft for ridge preservation - per site (D7953), and cone beam CT capture and interpretation with field of view 
of one full dental arch  maxilla, with or without cranium (D0366) provided on June 27, 2022, and July 1, 2022
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone graft at time of implant placement (D6104) and re-
cement or re-bond implant/abutment supported crown (D6092). 
 
You asked the Plan to pre-approve bone graft and re-cement implant/crown. You say that this should be 
covered. The Plan denied your request. The Plan says this is not a covered service. 
 
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 bone 
graft at time of implant placement (D6104) and re-cement or re-bond implant/abutment supported crown 
(D6092).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on 
December 14, 2022. 
 
You asked the Plan to pay for the dental service. You say that you think the Plan should have covered the 
evaluation. 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 the enrollees benefit for the requested item or service was exhausted on the date of service of August 
23, 2022. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation 
(D0150) provided on December 14, 2022.