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

 
We decided that the Plan does not have to pre-approve Prolastin-C. 
 
You asked the Plan to pre-approve Prolastin-C. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
 
 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Prolastin-C. 
  
Benefits for Prolastin-C may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the dental cleaning (D1110), panoramic 
radiographic image (D0330), periodic oral evaluation (D0120), treatment of a root canal obstruction (D3331), a 
pontic-porcelain fused to predominantly base metal (D6241), a core buildup including any pins when required 
(D2950), fixed partial denture sectioning (D9120 x 2), intraoral-periapical each additional radiographic image 
(D0230), and the therapeutic, prophylactic, or diagnostic injection (96372) provided from October 20, 2022, 
through November 2, 2022. 
 
  
 
 
You asked the Plan to issue reimbursement for these items/services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the 
items/services provided in this case are not payable as they were rendered outside of the country and were not 
emergent in nature.  
 
The Plan must follow Medicare rules. The rules say that worldwide emergency care is covered when needed to 
evaluate or stabilize an emergency medical condition. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the services provided do not meet 
criteria for coverage. Specifically, the dental services in this case were provided outside of the country. The 
Plan contract states that worldwide emergency care is covered when needed to evaluate or stabilize an 
emergency medical condition. The information provided does not substantiate an emergency medical condition 
that would necessitate the services rendered in this case. Therefore, we decided that the Plan does not have to 
issue reimbursement for the dental cleaning (D1110), panoramic radiographic image (D0330), periodic oral 
evaluation (D0120), treatment of a root canal obstruction (D3331), a pontic-porcelain fused to predominantly 
base metal (D6241), a core buildup including any pins when required (D2950), fixed partial denture sectioning 
(D9120 x 2), intraoral-periapical each additional radiographic image (D0230), and the therapeutic, 
prophylactic, or diagnostic injection (96372) provided from October 20, 2022, through November 2, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (70100, 74240, 74230, 99204) provided 
on December 8, 2022. 
 
You asked the Plan to pay for the radiology services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 70100, 74240, 74230, & 99204 is not supported in the medical record. Specifically, the 
claim was not billed with a valid place of service. The records show this was a mobile service. Place of Service 
11 is not supported by the documentation. Based on this information, we decided that Medicare rules for 
coverage of the radiology services have not been met. Therefore, we decided that the Plan does not have to pay 
for radiology services (70100, 74240, 74230, 99204) provided on December 8, 2022.
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 it is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet the requirements for approval. 
 
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 enrollees 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 pneumonia, neck hematoma, ruptured aneurysm, and urinary tract infection. Medical 
problems are stable. 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 this 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a transthoracic echocardiography rendered on July 24, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 93306-26 (1 Units) remains not supported. 
 
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 93306 is "Echocardiography, transthoracic, real-time 
with image documentation (2D), includes M-mode recording, when performed, complete, with spectral 
Doppler echocardiography, and with color flow Doppler echocardiography." 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that a review of the records indicates that transthoracic echocardiogram was performed on July 23, 2022, rather than the billed date of service - July 
24, 2022. The exam was then signed on July 25, 2022. 
 
We looked at this coder'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 transthoracic echocardiography rendered on July 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the sacroiliac (SI) joint injection (27096). 
 
You asked the Plan to pre-approve the injection. You say that the injection is medically necessary. The Plan 
denied your request. The Plan says the injection is not 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 pre-approve the injection. Our physician reviewer 
found that the Medicare LCD requires 75 percent pain relief from the diagnostic block and 50 percent pain 
relief for 3 months from a therapeutic block. The criteria of the LCD have not been met; therefore, the request 
is deemed not medically reasonable and 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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the sacroiliac (SI) joint injection (27096).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the spinal injection provided on February 
13, 2023. 
 
You asked the Plan to waive the copayment for the spinal injection. You say that this creates a financial burden 
for you. 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 $250 
copayment for outpatient surgery provided at an ambulatory surgical center. 
 
You have been asked to pay a $250 copayment for the spinal injection. This item/service falls within the 
outpatient surgery provided at an ambulatory surgical center 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 spinal injection provided on February 13, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-ray services provided on December 21, 2022. 
 
You asked the Plan to pay for x-ray services. You say that this service is supported in the records. 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 x-ray services provided 
on December 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 11, 2023, billed with 
codes 87481, 87640, 87653, and 87798. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
January 11, 2023, billed with codes 87481, 87640, 87653, and 87798.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 15, 2022. 
 
You asked the Plan to pay for an office 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 an office visit provided 
on December 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64454 for date of service January 11, 2023. 
 
You asked the Plan to pay for procedure code 64454. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage for code 64454 is limited to specific 
diagnosis codes. Any diagnosis code not listed is not covered. 
 
We looked at the file and Medicare rules. Review of the file shows that code 64454 was billed with diagnosis 
code M17.0 (bilateral primary osteoarthritis of knee). Diagnosis M17.0 is not listed as a covered diagnosis code 
for code 64454. The claim is not payable as billed. Based on this information, we decided that Medicare rules 
for coverage of procedure code 64454 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 64454 for date of service January 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic procedure provided on December 05, 2022. 
 
You asked the Plan to pay for therapeutic procedure. You say that you are requesting the submitted 
documentation be reviewed. 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 therapeutic procedure 
provided on December 05, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care provided on March 16, 2023, to 
March 17, 2023. 
 
You asked the Plan to pay for subsequent hospital care. You say that you are appealing the claim payment 
denial. 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 subsequent hospital care 
provided on March 16, 2023, to March 17, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for  the inpatient hospital stay provided from 
October 25, 2022, to October 27, 2022. 
 
You asked the Plan to waive the copayment for  the inpatient hospital stay. You say that you would like this 
charge removed since the beneficiary has passed away. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $440 copayment per day for days 1-5 of each inpatient hospital stay. The enrollees contract with the Plan also clearly says that enrollees then pay a $0 copayment per day for days 6-90 of each inpatient 
hospital stay.  
 
The enrollee has been asked to pay a $440 copayment per day for days 1-2 of the inpatient hospital stay. This 
item/service falls within inpatient hospital care benefit category. The enrollee has not been charged after day 
two or for the day of discharge. The enrollee has been asked to pay a total of $880 ($440 copayment per day x 
2 days = $880). This means that the enrollee has been asked to pay the correct amount based on the contract 
with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for  the inpatient hospital stay 
provided from October 25, 2022, to October 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on February 23, 2022. 
 
You asked the Plan to pay for laboratory services. You say that the services 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 laboratory services 
provided on February 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for targeted genomic sequence analysis panel provided on May 
13, 2021. 
 
You asked the Plan to pay for targeted genomic sequence analysis panel. You say that the services 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 targeted genomic 
sequence analysis panel provided on May 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device (33289). 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that the clinical value and effectiveness of 
this device has not been demonstrated in the peer-reviewed literature. The Plan denied your request. The Plan 
says this device is medically reasonable and 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 a CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the CardioMEMS device was approved by the Food and Drug Administration 
(FDA) in 2014 and consists of a sensor device placed in the pulmonary artery to allow measurement of 
pulmonary artery pressure in the management of patients with congestive heart failure (CHF). The clinical study on which FDA approval was based showed improved clinical outcomes and decreased hospitalizations in 
patients in whom the CardioMEMS system was implanted, reflecting a patient population with preserved 
ejection fraction and was somewhat limited in scope.Nonetheless, there remains a dearth of randomized, 
blinded clinical studies examining long-term clinical outcomes establishing the value of CardioMEMS in 
patient management. As a result, at this time the CardioMEMS system would not be considered medically 
appropriate and necessary in this enrollees clinical management. 
 
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 CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device (33289).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for the laboratory services provided on August 
10, 2022. 
 
You asked the Plan to reduce the cost share for the lab services. You say that you would like the Plan to cover 
more of this service. 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 $450 deductible which applies to in-network outpatient diagnostic 
tests and therapeutic services and supplies. Your contract with the Plan also says that there is a $10 copayment 
per day, per provider, for in-network Medicare-covered lab services. 
 The enrollee has been asked to pay $303.44, which satisfies the remaining deductible for the lab services. The 
Plan has followed Medicare rules by clearly disclosing in the contract that there is a $450 deductible which 
applies to outpatient diagnostic tests and therapeutic services and supplies. This cost sharing is a contractual 
obligation that had not been met at the time the lab services was received on August 10, 2022.  
 
You have also been asked to pay a $10 copayment for the lab services. You have been asked to pay a total of 
$313.44 ($303.44 deductible + $10 copayment = $313.44). This item/service falls within the outpatient 
diagnostic tests and therapeutic services and supplies 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 reduce the 
cost share for the laboratory services provided on August 10, 2022.