Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of impacted tooth (D7240) for tooth #17 and the 
deep sedation (D9222 and D9223) provided by on May 12, 2023. 
 
You asked the Plan to pay for the dental services. You say that the Plan should cover the services because it 
was a surgery and not dental because you had to have your wisdom tooth removed. The Plan denied your 
request. The Plan says the denial of payment for these services is correct because the removal of impacted tooth 
and the deep sedation are not covered by the Plan. 
 
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. 
 
The removal of impacted tooth and the deep sedation in dispute meets the Medicare definition of dental, since 
it is a service which involved the care and treatment of teeth or structures directly supporting the teeth. The 
removal of impacted tooth and the deep sedation do not fall under any of Medicare exceptions for coverage of 
non-routine dental care. 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 the removal of impacted tooth (D7240) for tooth #17 and the deep sedation (D9222 and D9223) 
provided by on May 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pharmacogenomics testing provided on January 24, 2023. 
 
You asked the Plan to pay for pharmacogenomics testing. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says these codes are not supported for payment. 
 
The Plan follows Medicare rules. Medicare rules state that if a lab runs more than two distinct procedural 
pharmacogenomics testing services on a single date of service, then the lab must use the -59 modifier with each 
additional service billed as an attestation that it is a distinct procedure service. 
 
We asked our coding 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 pharmacogenomics testing. Our reviewer 
says that these codes do not meet criteria for payment. Our physician reviewer found procedures performed 
should be reported with a panel procedure code. Separate billing cannot be supported as there is a more 
appropriate way to report the procedures performed. 
 
We looked at this coders review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of pharmacogenomics testing have not been met. Therefore, we decided that the 
Plan does not have to pay for pharmacogenomics testing provided on January 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have for the core buildup, including any pins when required for tooth 
number 31 (D2950) provided on March 28, 2023. 
 
You asked the Plan for this dental item. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says this dental item 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 Plan's coverage rules apply in this case. 
  
Though the Plan offers a dental benefit in excess of Medicare coverage, the dental item provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have for the core buildup, 
including any pins when required for tooth number 31 (D2950) provided on March 28, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a limited oral evaluation (D0140) provided on January 23, 2023. 
 
You asked the Plan to pay for the oral evaluation. You say that you contacted the Plan multiple times to locate 
an in-network provider. The Plan denied your request. The Plan says that while the rendering provider is 
contracted, the claim was submitted without the providers licensing information so the claim processed out-of-
network for not being able to identify a specific provider. 
 
Medicare rules say that a contract provider is an agent of the Plan. Services and referrals given by a contract 
provider are considered approved by the Plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
The Plan has confirmed multiple times that the oral evaluation was provided by a contract provider. The file 
does not show that the Plan provided notice that the service would not be covered. You do not control how the 
contract provider submits the claim and should not be held liable for missing contract licensing information. 
Since this service was provided by a contract provider, under Medicare rules this service is considered covered 
by the Plan. Therefore, we decided that the Plan has to pay for a limited oral evaluation (D0140) provided on 
January 23, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health visits beyond February 1, 2024. 
 
You asked the Plan to pre-approve additional home health visits. You say that you are waiting to get assistance 
with home health because no one has showed up and you feel that this is unprofessional. The Plan denied your 
request. The Plan says the requested home health visits is not medically necessary under Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of home health visits have been met. 
Medical records were not provided for this case. The record shows that the Plan made multiple attempts to 
obtain this information, but it was not received. Without medical records we are unable to determine if the 
criteria for coverage were met. Therefore, we decided that the Plan does not have to pre-approve home health 
visits beyond February 1, 2024.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on March 9, 2023, to April 8, 
2023, billed with procedure code E0431-RR-KX (31 units). 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
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 E0431-RR-KX (31 units) is portable gaseous oxygen 
system, rental; includes portable container, regulator, flowmeter, humidifier, cannula or mask, and tubing. 
 
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 practitioner services provided. Our reviewer says that documentation does not support the billed code. Our reviewer found that 31 units of E0431 are not supported. 
The record shows that one unit was provided. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on March 9, 2023, to April 8, 2023, billed with 
procedure code E0431-RR-KX (31 units).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies provided on July 12, 2023. 
 
You asked the Plan to pay for the wound care supplies. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The 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 the wound care supplies 
provided on July 12, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the continued inpatient services provided from January 1, 2023, to 
April 23, 2023. 
 
You asked the Plan to pay for the continued inpatient services. You say that you disagree with the denial of 
continued inpatient services based on Centers for Medicare & Medicaid Services (CMS) guidelines. You also 
say that you are confident the provided medical services qualify this patient's continued stay at the facility. The 
Plan denied your request. The Plan says that retrospective authorization was denied due to the Plan's policy 
requiring retrospective authorizations to be received within 30 days of date of service. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 continued inpatient services. Our 
reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the patient was admitted to the hospital on December 14, 2022, due to Acute and 
Chronic Respiratory Failure with Hypoxia as an Elective admission. The patient received ventilator 
management and was status post tracheostomy and percutaneous endoscopic gastrostomy (PEG) tube 
placement. Our reviewer found that the enrollee required hemodialysis for end-stage renal disease and multiple 
courses of intravenous antibiotics. The patient had sacral wounds that required wound care and had a biopsy for 
calciphylaxis. Our physician reviewer also found that the review has determined that the record showed that at 
the time of inpatient admission it was reasonable for the admitting physician to expect that the patient's 
necessary hospital care (including earlier emergency department and/or observation care) would span two 
midnights with supporting documentation of the patients history and comorbidities, signs and symptoms, 
current medical needs, and risk of an adverse event. 
 
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 continued inpatient services have been met. Therefore, we decided that the 
Plan has to pay for the continued inpatient services provided from January 1, 2023, to April 23, 2023.  
 
  If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and laboratory service provided on September 
21, 2023. 
 
You asked the Plan to pay for the office visit and laboratory service. You say that you are requesting 
reconsideration of the denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The 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 the office visit and 
laboratory service provided on September 21, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device insertion. 
 
You asked the Plan to pre-approve the Vertiflex device insertion. You say that the enrollee has back pain and 
does not have an effective treatment. You say that the enrollee needs a treatment that does not involve 
medications. The Plan denied your request. The Plan says the Vertiflex device is 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 Vertiflex device insertion. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the Vertiflex device is considered experimental. 
 
  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 Vertiflex device insertion have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Vertiflex device insertion.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on August 23, 
2023. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the 
copayment. 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 $305 
copayment for ambulance services. 
 
You have been asked to pay a $305 copayment for ambulance services. This item/service falls within the 
ambulance 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 ambulance services 
provided on August 23, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient diagnostic tests provided on 
February 03, 2023, to September 01, 2023. 
 
You asked the Plan to waive the copayment for outpatient diagnostic tests. You say that you disagree with the 
copayment. 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 $25 
copayment for outpatient diagnostic tests/Medicare-coveredoutpatient diagnostic. 
 
You have been asked to pay a $25 copayment for outpatient diagnostic tests. This item/service falls within the 
outpatient diagnostic tests/Medicare-coveredoutpatient diagnostic 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. However, since the allowed amount is less than the 
standard copayment, you only owe $15.62 per visit. The total amount you are being asked to pay is $31.24 
($15.62 x 2 visits = $31.24). Therefore, we decided that the Plan does not have to waive the copayment for 
outpatient diagnostic tests provided on February 03, 2023, to September 01, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the use of Keytruda Solution 100mg/4ml.  
 
You asked the Plan to pre-approve the medication. You say that the use of Keytruda is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the enrollee does not meet the criteria for the use of 
Keytruda.  
 
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 medication. Our reviewer says that 
the enrollee does not meet the criteria for Keytruda. Our physician reviewer found the requested use of 
Keytruda is not FDA-approved for the enrollees diagnosis. The use is not supported by one of the major drug 
compendia or by clinical research that appears in a CMS-approved medical journal. The documentation does 
not support that the requested drug is safe and effective and otherwise reasonable and necessary for this 
enrollee.  
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the use of Keytruda Solution 100mg/4ml.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lower 
spinal canal.  
 
You asked the Plan to pre-approve the MRI. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the enrollee has not completed six weeks of provider directed treatment.  
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI. Our reviewer says that the 
MRI is not medically necessary. Our physician reviewer found the request does not meet criteria for approval. 
There is no documentation of recent 6-week conservative therapy and there is a lack of a detailed physical 
exam. 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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a magnetic resonance imaging (MRI) of the lower spinal canal.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lucentis. 
 
You asked the Plan to pre-approve Lucentis. You say that the requested Lucentis is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail Avastin and Byooviz 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 Lucentis. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the Plan requires a trial of Avastin 
and Byooviz first before they will approve the requested drug. In this case, the enrollee has not tried and failed 
the required drug(s). There is no documentation provided indicating that the Plans required drug(s) would 
likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Lucentis have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Lucentis.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing billed with code 81479 for date of service 
September 15, 2023. 
 
You asked the Plan to pay for the testing billed with code 81479. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim for this molecular pathology testing did not 
include the required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the testing billed with 
code 81479 have not been met. Therefore, we decided that the Plan does not have to pay for the testing billed 
with code 81479 for date of service September 15, 2023.