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

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on June 6, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says code 87150 (11 units) remains not supported. The place of service(POS) on the CMS-
1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted 
claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted 
medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 
11. Also, the laboratory results submitted indicate the specimen was collected on June 6, 2020 and received by 
the lab on June 9, 2020. It is also noted the enrollee resides in New York and the billing laboratory is located in 
New Jersey; therefore, the billed code cannot be verified. It is noted multiple attempts were made to obtain 
additional information from the provider.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, the claim was submitted with an invalid 
POS code. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay for 
lab services provided to the enrollee on June 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve excision of tongue lesions (D7410, D7411). 
 
You asked the Plan to pre-approve excision of tongue lesions. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or 
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve excision of tongue 
lesions (D7410, D7411).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 22 additional Hyperbaric Oxygen Therapy (HBO) 
treatments (G2077). 
 
You asked the Plan to pre-approve 22 additional HBO treatments. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that HBO therapy is covered under specific 
circumstances. 
 
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 22 additional HBO treatments. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has been 
receiving hyperbaric oxygen therapy but the wound has not demonstrated healing in the past 30 days. 
 
On November 20, 2020 the wound measured 0.5cm x 0.5cm x 2.2cm. On December 22, 2020 the wound had 
increased to 0.9cm x 1cm x 3cm. Per the Guidelines hyperbaric oxygen is not covered if there are no 
documented measurable signs of healing during the past 30 days of treatment. The review has determined the 
enrollee does not meet the coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 22 additional HBO treatments have not been met. Therefore, we decided that 
the Plan does not have to pre-approve 22 additional Hyperbaric Oxygen Therapy (HBO) treatments (G2077).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an EGD provided on April 21, 2020. 
 
You asked the Plan to waive the copayment for an EGD. You say that you paid your copayment at the time of 
service and are now receiving additional charges. The Plan denied your request. The Plan says the claims were 
processed correctly, and you are being charged the correct amount. 
 
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 $325 
copayment for outpatient surgery, including services provided at hospital outpatient facilities. 
 
You received an EGD on April 21, 2020. An EGD is considered an outpatient surgical procedure. Therefore, 
you are responsible to pay the $325 copayment.   
 
You have been asked to pay a $325 copayment for an EGD. An EGD falls within the outpatient surgery, 
including services provided at hospital outpatient facilities and ambulatory surgical centers 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 EGD provided on April 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation and preventive 
procedure provided on August 24, 2020. 
 
You asked the Plan to pay for the problem focused limited oral evaluation and preventive procedure. You say 
that the x-rays were not taken at this providers office, and you only received a very limited exam. You also say 
that you have 100% coverage for extractions and x-rays. The Plan denied your request. The Plan says these 
services are not covered benefits. The Plan also says that participating providers are receiving a separate 
monthly stipend for the unspecified preventive procedure. 
 
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 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 
problem focused limited oral evaluation and preventive procedure provided on August 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on August 5, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent 
nor urgent and prior authorization was not obtained to provide out-of-network care. 
 
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 has network providers 
available who can provide 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 physician services provided on August 5, 2020 
by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided from September 16, 2020, 
through October 9, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 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 says that the Plan has also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
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 
physicians services. 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 physician's services provided from September 16, 2020, 
through October 9, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 6 physical therapy (PT) visits (97110). 
 
You asked the Plan to pre-approve 6 PT visits. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 6 PT visits. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of your condition. 
Our physician reviewer found based on the medical records provided there is no documentation that the 
specialized skill, knowledge and judgment of a qualified therapist is required to establish, design and/or deliver 
a program to maintain your current condition or to prevent or slow further deterioration. Based on the available 
records you have improved with therapy and are mostly pain-free with the ability to perform your home 
exercises and activities of daily living. Further therapy at this point does not appear to be likely to achieve any 
significant improvement in the your symptoms or functional status; continued exercise with your home 
exercise program appears to be indicated at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 6 PT visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 6 physical therapy (PT) visits (97110).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the TENS services provided to the enrollee on August 30, 
2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that TENS is not reasonable and necessary for the 
treatment of CLBP under section 1862(a)(1)(A) of the Act.  
 
We looked at the file and Medicare rules. Per NCD 160.27, the requested TENS services are considered not 
medically reasonable and necessary for the enrollee in this case. 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 the TENS services provided to the enrollee on August 30, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy (S9328) provided on February 10, 
2020. 
 
You asked the Plan to pay for the home infusion therapy. You say that the services provided were medically 
necessary and you would like this claim reprocessed and approved for payment. The Plan denied your request. 
The Plan says the code you have billed is not valid for Medicare purposes. 
 
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 S9328 is home infusion therapy, implanted pump pain 
management infusion. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home infusion therapy services have not been met. Specifically, the code billed (S9328) is not 
covered by Medicare or the Plan. Medicare uses another code for reporting of, and payment for, these services. 
Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not 
been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy (S9328) 
provided on February 10, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest and abdomen x-rays rendered on June 17, 2020 and 
June 19, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure codes 71045 and 74018 are 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 71045 is radiologic examination, chest; single view. The 
definition of code 74018 is radiologic examination, abdomen; 1 view. 
 
We find that CPT codes 71045 and 74018 are not supported in the medical record. Specifically, the records 
support two units of code 71045, which have been paid. There is no documentation to support billing of further 
units of this code. The documentation supports one unit of code 74018, which has been paid. The 
documentation does not support the billing of further units of this code. Based on this information, we decided 
that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does 
not have to pay for the chest and abdomen x-rays rendered on June 17, 2020 and June 19, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found no skilled nursing services are identified. 
The documentation does not support that skilled services on a daily basis are medically reasonable and 
necessary at this point, as the enrollee is stable at the level she was when she left the SNF in December, 2020. 
 
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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory work provided on August 3, 
2020. 
 
You asked the Plan to waive the copayment for the laboratory work. You say that you were unaware that you 
would be responsible for this charge. The Plan denied your request. The Plan says you have been charged the 
correct cost sharing amount. 
 
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 $10 
copayment for each in-network covered laboratory service. (This copayment may not apply if you visit a PCP 
or specialist on the same date of service that the laboratory service was performed, and you plan has an office 
visit copayment for that visit).  
 
You have been asked to pay a $10 copayment for the laboratory work. The laboratory work 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 waive the copayment for the laboratory work provided on August 3, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided August 29, 2019 and 
August 30, 2019 by Aspirus Hospital. 
 
You asked the Plan to pay for self-administered drugs under Medicare Part B. You say that the Plan should 
cover this bill. The Plan denied your request. The Plan says payment for self-administered drugs should be 
submitted to Medicare Part D. 
 
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 pay for self-administered drugs provided 
August 29, 2019 and August 30, 2019 by Aspirus Hospital.  
 
Benefits for self-administered drugs 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the x-ray provided on August 11, 2020. 
 
You asked the Plan to waive the copayment for the x-ray. You say that you should not be responsible for this 
copayment because the first x-ray should have been done correctly so you would not have needed the second x-
ray. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
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 $50 
copayment for each basic imaging service (e.g., general x-rays or ultrasound).  
 
You have been asked to pay a $50 copayment for the x-ray. The x-ray falls within the ?Outpatient diagnostic 
test and therapeutic services and supplies? benefit category. The record shows two separate x-rays were 
completed. 
 
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 x-ray provided on August 11, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interspinous spacer placement (22870, 22869). 
 
You asked the Plan to pre-approve the interspinous spacer placement. You say that the service is medically 
necessary. The Plan denied your request. The Plan says this item is not covered at this time. 
 
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 interspinous spacer placement. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the Vertiflex spacer device requested is considered experimental. More research 
is needed to show safety and efficacy. 
 
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 interspinous spacer placement have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an interspinous spacer placement (22870, 22869).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the simple extraction and surgical extraction provided on 
March 1, 2019, by an OON provider. 
 
You asked the Plan to pay for the extractions. You say that you believe this claim was denied in error. You also 
say that you did have some coverage for OON dentistry. The Plan denied your request. The Plan says the 
simple extraction is not covered under the Plan. The Plan also says that the surgical extraction is not a covered 
service under your contract. 
 
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 requested items or services are not 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the simple 
extraction and surgical extraction provided on March 1, 2019, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on May 13, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that certain conditions have both an underlying 
etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the 
ICD10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, 
followed by the manifestation. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the requested services have not been met. Specifically, the record shows that the claim was billed 
with only primary diagnosis code F06.31. This code has a code first note, which means it is a manifestation 
code and must be sequenced after an etiology code. Therefore, we decided that the Plan does not have to pay 
for the services provided on May 13, 2020.