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

 
We decided that the Plan does not have to pay for the eye examination and the contact lens fitting provided on 
June 5, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the eye examination and the contact lens fitting. You say that you have seen this 
provider for the past two years and the services were covered. You say the services should continue to be 
covered. The Plan denied your request. The Plan says the provider was out-of-network. 
 
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 did not pre-approve the 
eye examinations and contact lens fitting. We found no exception that would require the Plan to pay for these 
services. Therefore, we decided that the Plan does not have to pay for the eye examination and the contact lens 
fitting provided on June 5, 2023, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a gastrointestinal (GI) tract imaging (91110). 
 
You asked the Plan to pre-approve a GI tract imaging. You say that a colonoscopy and upper GI were 
completed, and you would like the denial to be reconsidered. The Plan denied your request. The Plan says the 
enrollee does not meet the criteria for a wireless capsule endoscopy. 
 
The Plan follows Medicare rules. Medicare rules say that a wireless capsule endoscopy of the small bowel or 
esophagus is considered medically reasonable and necessary when the conditions listed in the Medicare rules 
section of this letter have been met. 
 
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 GI tract imaging. Our reviewer says 
that the patient does not meet the criteria for coverage. Our physician reviewer found the patient has iron 
deficiency anemia, but her colonoscopy is not up to date, so criteria for small bowel capsule endoscopy for 
either the small bowel or esophagus are not met, and are 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 a GI tract imaging have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a gastrointestinal (GI) tract imaging (91110).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 3, 2023, by an 
OON provider.  
 
You asked the Plan to pay for the lab services. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says the service was not authorized. 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 contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
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 the laboratory services provided on April 3, 2023, 
by an OON provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for service(s) provided between 10:00 PM and 8:00 AM at 24-
hour facility, in addition to basic service (99053) and patient not eligible due to active diagnosis of 
hypertension (G9744) provided April 29, 2023. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says procedure code 99053 is considered bundled and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Furthermore, G9744 is only used for reporting with no value 
amount to it. Therefore, we decided that the Plan does not have to pay for service(s) provided between 10:00 
PM and 8:00 AM at 24-hour facility, in addition to basic service (99053) and patient not eligible due to active 
diagnosis of hypertension (G9744) provided April 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network cardiology visit provided on 
June 01, 2023. 
 
You asked the Plan to waive the copayment for an in-network cardiology visit. You say that you did not see 
this provider on this day. 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 $35 
copayment for Physician/Practitioner services, including doctors office visits. 
 
You have been asked to pay a $35 copayment for an in-network cardiology visit. 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. Therefore, we decided that the Plan does not have 
to waive the copayment for an in-network cardiology visit provided on June 01, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - comprehensive x-rays (D0210) provided on July 
12, 2023. 
 
You asked the Plan to pay for intraoral - comprehensive x-rays (D0210). You say that it is your understanding 
that because the services are part of the screening process for your upcoming aortic valve replacement, and was 
ordered by the cardiothoracic surgeon, that it would be covered. The Plan denied your request. The Plan says 
per the 2023 EOC, this service 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 pay for intraoral - 
comprehensive x-rays (D0210) provided on July 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an emergency response system (S5161). 
 
You asked the Plan to pre-approve an emergency response system. You say that the item should be covered. 
The Plan denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an emergency response system (S5161). This item may be 
covered with the Plans over-the-counter (OTC) plus card.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for emergency department visit provided out of country on February 18, 
2021. 
 
You asked the Plan to pay for the emergency department visit. You say that you are requesting reimbursement 
for the emergency services. The Plan denied your request. The Plan says that the denial of reimbursement is 
correct, because the enrollee was living out of country for more than 6 months. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 emergency department visit. Our 
reviewer says that the emergency department visit was medically reasonable and necessary. Our physician 
reviewer found that the enrollee presented on February 18, 2021, and was found to have a right forearm 
fracture with soft tissue swelling. 
 
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 emergency department visit have been met. Therefore, we decided that the 
Plan has to pay for emergency department visit provided out of country on February 18, 2021.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81433 for date of service May 19, 2023. 
 
You asked the Plan to pay for procedure code 81433. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not separately payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel constitutes a single procedural service, so 
one HCPCS codes must be submitted for the panel. 
 
We looked at the file and Medicare rules. Review of the file shows that the Plan did not submit this panel with 
one code. Based on this information, we decided that Medicare rules for coverage of procedure code 81433 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 81433 for date 
of service May 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), 
expandable controller (E2377), back cushion mount hardware (K0108), and seat cushion mount hardware 
(K0108). 
 
You asked the Plan to pre-approve an electronic connection, harness, expandable controller, back cushion 
mount hardware, and seat cushion mount hardware. The Plan denied your request. The Plan says although there 
are three requested power options (tilt, recline and elevating leg rests), there is not a medical need to control 
these power options through the joystick. The Plan also says that mounting hardware is included with the seat 
cushion and back cushion and cannot be requested separately. 
 
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 electronic connection, harness, and 
expandable controller. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the enrollee has intact gross motor 
function in their upper extremity. Our reviewer also found that the enrollee has sufficient strength and function 
in their upper extremities to manage standard power drives 
 
Medicare rules also say that there is no separate payment for mounting hardware for a seat or back cushion. 
 
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 electronic connection, harness, expandable controller, back cushion mount 
hardware, and seat cushion mount hardware have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an electronic connection (E2311), harness (E2313), expandable controller (E2377), back 
cushion mount hardware (K0108), and seat cushion mount hardware (K0108).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs appropriate level of 
care. You say that the enrollee has been to a skilled nursing facility and did not receive the care needed for a 
specialized trach. The Plan denied your request. The Plan says an LTACH admission is not medically 
necessary.  
 
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 that the enrollee does not have any medical needs that can only be met at an LTACH. 
Additionally, the enrollee does not require care provided at an LTCH for a length of stay near 25 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to reduce the cost sharing for the gene expression test. We decided that the Plan 
does not have to waive the cost sharing for the gene expression test.  
 
You asked the Plan to waive the cost sharing for the breast cancer gene expression test provided on May 9, 
2023. You say that you were told that the test was a covered procedure. The Plan says that this cost sharing was 
charged correctly. 
 
We decided that the Plan has to reduce the cost sharing for the gene expression test.  
 
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 enrollees must pay a 20% coinsurance for molecular or predisposition genetic 
testing. The Plan says you must pay a $774.60 coinsurance for the gene expression test, which is more than a 
20% coinsurance. Based on the Plan contract, however, you cannot be asked to pay more than a 20% 
coinsurance for the gene expression test. Therefore, we decided that the Plan has to reduce the cost sharing for 
the gene expression test.  
 
We also decided that the Plan does not have to waive the cost sharing for the gene expression test. 
 
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 20% 
coinsurance for molecular or predisposition genetic testing. Therefore, we decided that the Plan does not have 
to waive the cost sharing for the gene expression test. 
 
The gene expression test falls within the outpatient diagnostic tests and therapeutic services and supplies 
benefit category. This means that you are responsible for a $762.21 coinsurance based on your contract with 
the Plan ($3811.03 allowed amount x .20 = $762.21 rounded up). 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 cost sharing for the gene expression test. 
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve physical therapy services with an out-of-network provider. You say that you 
want the Plan to approve the services with this provider. The Plan denied your request. The Plan says the 
requested provider is out-of-network. These services are available in-network. 
 
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 
physical therapy services to be provided by an out-of-network (OON) provider.
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 admission to an inpatient rehabilitation facility is 
medically necessary. The Plan denied your request. The Plan says the requirements for admission to an 
inpatient rehabilitation facility have 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee's medical problems are stable and there are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies and an intensive 
rehabilitation therapy program. While the medical record supports a need for physical or occupational therapy, 
there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Darzalex, Cisplatin, and gemcitabine. 
 
You asked the Plan to pre-approve the drugs. You say that you would like the enrollee to receive this 
chemotherapy regimen. The Plan denied your request. The Plan says Darzalex, Cisplatin, and gemcitabine are 
not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 the drugs. Our reviewer says that 
Darzalex, Cisplatin, and gemcitabine are not medically necessary. Our physician reviewer found that the 
requested use of Darzalex, Cisplatin, and gemcitabine are not FDA-approved. Darzalex, Cisplatin, and 
gemcitabine are also not supported by one of the major drug compendia or by clinical research. 
 
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 drugs have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Darzalex, Cisplatin, and gemcitabine.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty (22514, 22515). 
 
You asked the Plan to pre-approve kyphoplasty. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary because the records show the enrollee's onset of 
symptoms was more than 12 weeks ago and the enrollee has evidence of severe spinal canal stenosis on 
imaging that is likely contributing to the pain. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be covered when specific criteria are 
met. 
 
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 kyphoplasty. Our reviewer says that the 
enrollee does not meet criteria for coverage. Our physician reviewer found detailed documentation is not 
evident regarding the L5 fracture being acute or subacute. Additionally, there is no documentation of a 
progression of the body height loss, greater than 25% vertebral body height loss, kyphotic deformity, or a 
severe impact on daily activities. Moreover, there is magnetic resonance imaging corroboration of other 
plausible causes of pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty (22514, 22515).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a joystick armor cover (K0108). 
 
You asked the Plan to pre-approve a joystick armor cover. You say that the item in question is not an integral 
part of the base, thus a split decision should be possible. The Plan denied your request. The Plan says this does 
not serve a medical purpose and cannot be covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a joystick armor cover (K0108).