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

 
We decided that the Plan does not have to pay for the DecisionDX-Melanoma testing (81529) provided on 
September 27, 2022.  
 You asked the Plan to pay for the DecisionDX-Melanoma testing. You say that this testing is a covered benefit.  
The Plan denied your request. The Plan says the enrollee has tumor stage T1a with no such concern regarding 
the adequacy of microstaging documented.  
 
The Plan follows Medicare rules. Medicare rules say that molecular diagnostic tests used to assist in risk 
stratification of melanoma patients are covered when the enrollee has a personal history of melanoma and 
either Stage T1b and above or has T1a with documented concern about adequacy of microstaging. 
 
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 testing. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found that this enrollee with a 
T1a cutaneous melanoma does not meet the above criteria for DecisionDx melanoma. There are no high-risk 
features and testing is unlikely to change management. The use of DecisionDx Melanoma was not reasonable 
or 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 the DecisionDX-Melanoma testing have not been met. Therefore, we decided 
that the Plan does not have to pay for the DecisionDX-Melanoma testing (81529) provided on September 27, 
2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a continuous glucose monitor (CGM). You say that you would like to 
request reconsideration of the denied authorization. The Plan denied your request. The Plan says that the 
services requested are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 a continuous glucose monitor (CGM). 
Our reviewer says that the service is medically necessary. Our physician reviewer found the enrollee is having 
low BGS as a complication of their gastric surgery for their esophageal cancer. The CGM will help the enrollee 
and avoid severe lows BGS which can occur as a complication of their surgery. 
 
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 continuous glucose monitor (CGM) have been met. Therefore, we decided 
that the Plan has to pre-approve a continuous glucose monitor (CGM).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for immunizations received on November 26, 2021. 
 
You asked the Plan to pay for the immunizations. You say that you sought advice on appropriate vaccines for 
volunteer work in India and were directed to receive these vaccinations. The Plan denied your request. The 
Plan says the denial of payment was correct. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the immunizations. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the immunizations. 
Therefore, we decided that the Plan does not have to pay for immunizations received on November 26, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Hematology Profile testing (81455) provided on November 22, 
2022. 
 
You asked the Plan to pay for the Hematology Profile testing. You say that this testing was medically 
necessary.  The Plan denied your request. The Plan says that the records do not document a diagnosis of 
myelodysplastic or myeloproliferative disorders. In addition, bone marrow suppression is thought to be due to 
immunosuppression or infection  
 
The Plan follows Medicare rules. Medicare rules say that the criteria for coverage listed in the rules section of 
this letter must be met for coverage. 
 
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 Hematology Profile testing. Our 
reviewer says that criteria for coverage are met for this service. Our physician reviewer found that the use of 
next generation sequencing is a standard of care for the diagnosis and treatment of patients with suspected 
myelodysplastic syndrome. This use is supported by the NCCN Guidelines. This enrollee fits this criterion. The 
service was reasonable and 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 the Hematology Profile testing have been met. Therefore, we decided that the 
Plan has to pay for the Hematology Profile testing (81455) provided on November 22, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for in-network orthopedic visits provided on 
November 16, 2022, to November 29, 2022. 
 
You asked the Plan to waive the copayment for in-network orthopedic visits. You say that you were only seen 
by technicians for these visits, to change your cast. 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 $30 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $30 copayment for in-network orthopedic visits. 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. You had two visits, each with a $30 copayment 
($30 x 2 = $60). This resulted in a total copayment of $60, which you are being asked to pay. These visits are 
still held in a specialist area, resulting in a specialist copayment. Therefore, we decided that the Plan does not 
have to waive the copayment for in-network orthopedic visits provided on November 16, 2022, to November 
29, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Botox injection. 
 
You asked the Plan to pre-approve a Botox injection. You say that a Botox injection is necessary because other 
injections have failed.  The Plan denied your request. The Plan says they have reviewed drug compendia and 
did not find conclusive evidence that Botox is effective for occipital neuralgia. 
 
The Plan must follow Medicare rules. Medicare rules say that only certain diagnoses support the medical 
necessity for the use of Botox (J0585). Occipital neuralgia, M54.81, is not listed as a diagnosis that supports 
medical necessity.  
 
We looked at the file and Medicare rules. The record shows that Botox is being requested for the treatment of 
occipital neuralgia, which is not a covered diagnosis. Based on this information, we decided that Medicare 
rules for coverage of the Botox injection have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a Botox injection. Therefore, we decided that the Plan does not have to pre-approve a Botox 
injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 12, 2022. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services provided. 
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 an office visit provided 
on July 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal surgery (20930, 22558, 22585, 22842, and 
22853). 
 
You asked the Plan to pre-approve spinal surgery. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
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 spinal surgery. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is no instability on imaging 
studies. Fusion is not needed for lumbar degenerative disc disease (ddd). 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of spinal surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve spinal surgery (20930, 22558, 22585, 22842, and 22853).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care services provided on October 03, 2022. 
 
You asked the Plan to pay for wound care services. You say that these services are medically necessary. 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 services 
provided on October 03, 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 20, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these services were 
medically necessary. 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 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient mental health provided on January 10, 2023, to 
January 20, 2023. 
 
You asked the Plan to pay for inpatient mental health. You say that you are requesting reconsideration for the 
services provided. 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 inpatient mental health 
provided on January 10, 2023, to January 20, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for inpatient care provided on November 8 to November 16, 2022. 
 
You asked the Plan to pay for the inpatient care. You say that this service was medically necessary. The Plan 
denied your request. The Plan says that the claim was not billed with a required modifier. 
 
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. The plan has not fully articulated the denial. The plan states that the physical 
therapy services were not billed with a required modifier. The services at issue are inpatient hospital services. 
The plan has not sufficiently supported the denial. Therefore, we decided that the Plan has to pay for inpatient 
care provided on November 8 to November 16, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontics (D6240) for teeth #22 and #23. 
 
You asked the Plan to pre-approve the dental services. You say that this dental work is needed. 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 with the approval of pontics for teeth #24, 
#25, #26, and #27. Therefore, we decided that the Plan does not have to pre-approve pontics (D6240) for teeth 
#22 and #23.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J3490 provided on February 3, 2023. 
 
You asked the Plan to pay for procedure code J3490. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment is included in the global surgery 
payment. 
 The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery. 
 
We looked at the file and Medicare rules. Payment for procedure code J3490 is included in the global surgery 
payment for procedure code 20610 provided on February 3, 2023. Separate payment cannot be made for 
procedure code J3490. Based on this information, we decided that Medicare rules for coverage of procedure 
code J3490 have not been met.  Therefore, we decided that the Plan does not have to pay for procedure code 
J3490 provided on February 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for each dialysis service provided on April 12, 
2022, to April 30, 2022. 
 
You asked the Plan to waive the coinsurance for each dialysis service. You say that these services were directly 
related to your dialysis treatment. 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 20% 
coinsurance for services to treat kidney disease.  
You have been asked to pay 20% coinsurance for each dialysis service. This item/service falls within the 
services to treat kidney disease 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 
each dialysis service provided on April 12, 2022, to April 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wound care visit provided on November 28, 2022. 
 
You asked the Plan to pay for a wound care visit. You say that this was medically necessary and should be 
covered. 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 wound care visit 
provided on November 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5261) provided on November 8, 2022. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says these items are not payable as they were rendered by 
an out-of-network provider, without prior authorization.  
 
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 issue reimbursement 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 at issue in this appeal.  
  
The Plan did not pre-approve the items at issue. We found no exception that would require the Plan to pay for 
these items. Therefore, we decided that the Plan does not have to pay for the hearing aids (V5261) provided on 
November 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. 
 
You asked the Plan to pre-approve a power wheelchair. You say that you need a power wheelchair. The Plan 
denied your request. The Plan says the coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair. Our reviewer says 
that the coverage criteria has not been met. Our physician reviewer found that you walk independently with a 
cane. You do not require a power wheelchair to perform your ADL's. 
 
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 power wheelchair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power wheelchair.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance stabilization services 
provided on January 17, 2023. 
 
You asked the Plan to waive the copayment for the ambulance stabilization services. You say that you thought 
a nurse would be sent and did not know an ambulance would be sent. 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 $270 
copayment for ambulance services, including stabilization services. 
 
You have been asked to pay a $270 copayment for the ambulance stabilization services. This item/service falls 
within the ambulance services, including stabilization 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 the ambulance stabilization services provided on January 17, 2023.