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

We decided that the Plan does not have to pay for the self-administered drugs and insulin injections provided on April 10, 2020 and April 11, 2020.
You asked the Plan to pay for the self-administered drugs and insulin. You say that none of the drugs were under your control, and none were self-administered while you were in the hospital. You also say that what you were given was deemed necessary by your doctor. The Plan denied your request. The Plan says these drugs are self-administered, and are not Part B covered.
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 the self-administered drugs and insulin injections provided on April 10, 2020 and April 11, 2020.
Benefits for the self-administered drugs and insulin 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two outpatient hospital clinic visits provided on January 
16, 2020. 
 
You asked the Plan to pay for the two outpatient clinic visits. You say that there are no bundling issue with 
these codes and this claim should be paid with interest. The Plan denied your request. The Plan says this was 
not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that multiple visits provided on the same date from 
the same revenue center must be identified with condition code G0. 
 
In this case, the claim is for two units of G0463, or two clinic visits. Billing for this requires the use of 
condition code G0, which is not present. Therefore, we decided that the Plan does not have to pay for the two 
outpatient hospital clinic visits provided on January 16, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the professional component of the lab testing provided from 
January 23, 2020 to February 2, 2020. 
 
You asked the Plan to pay for the lab testing professional components. You say that payment of the 
professional components of these tests is necessary in order to reimburse the provider for interpreting the data 
due to the complexity of transplant cases. The Plan denied your request. The Plan says these codes are not 
payable when billed for the professional component only. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The codes at issue are not payable on the Physician Fee Schedule but have a PC/TC indicator of "9" meaning 
that the concept of professional/technical components does not apply. These services are paid in the Clinical 
Laboratory Fee Schedule and only have a fee for the global service, and no breakdown for PC/TC of the 
service. This means that payment cannot be made for these codes when billed with the modifier -26. Based on 
this information, we decided that Medicare rules for coverage of the lab testing professional components have 
not been met. Therefore, we decided that the Plan does not have to pay for the professional component of the 
lab testing provided from January 23, 2020 to February 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) rendered by the out of network 
(OON) provider on June 26, 2019. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was provided by an out of network 
provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the office visit (99213) rendered by the out of network (OON) provider on June 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on February 24, 
2020. 
 
You asked the Plan to waive the copayment for the office visit. You say that you were charged the specialist 
copayment and this provider is not a specialist. 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 $20 
copayment for services obtained from an out-of-network primary care provider, or under certain circumstances, 
treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a 
primary care provider's office.  
 
You have been asked to pay a $20 copayment for the office visit. The office visit falls within the Physician/  
Practitioner Services, Including Doctor's Office Visits benefit category. The record shows this is an out-of-
network Family Medicine provider.  
 
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 office visit provided  on February 24, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing provided on September 11, 2019. 
 
You asked the Plan to pay for the drug testing. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says the order in this case is not signed. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing must be ordered by the treating 
provider. Though the order need not be signed, the record must demonstrate the intent that the testing be 
performed.  
 
In this case, there is an unsigned order for the provider's custom panel. No records are submitted to demonstrate 
the intent for this testing. Therefore, we decided that the Plan does not have to pay for the definitive drug 
testing provided on September 11, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on March 1, 2020.
You asked the Plan to pay for the testing services. You say that the physician ordered the testing to determine if there was a more effective therapy. The Plan denied your request. The Plan says Guardant360 testing requires use of CPT 81479, and the appropriate DEX Z identifier entered adjacent in the comment narrative field.
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 looked at the file and the rules. The provided claim does not show the services were billed using Medicare coding and billing guidance. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on March 1, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 testing provided on February 7, 2020. 
 
You asked the Plan to pay for genetic testing. You say that the treating physician ordered this testing to 
determine if there was a more effective therapy to treat the enrollee. The Plan denied your request. The Plan 
says the denial of payment for this testing is correct, because this testing was not billed with the appropriate 
coding. 
 
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be billed with CPT 
code 81479 for date of service February 7, 2020.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for 
Guardant360 testing provided on February 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on March 25, 2020. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the provider 
is not contracted with Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
the medical services provided on March 25, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for post-stabilization care provided to the enrollee from March 
18, 2019 through March 20, 2019. 
 
You asked the Plan to pay for post-stabilization care. You say that the claim should be paid. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 post-stabilization care. Our physician 
reviewer found the enrollee was stabilized in the emergency department and should have been considered for 
transfer to an approved facility.  Alternatively, approval could have been sought to admit the enrollee to the 
same hospital.  A request for pre-approval was not initiated and communication as requested by the plan on 
March 18, 2019 was not completed. Without the request or granted pre-approval, post stabilization care (care 
delivered after emergency department stabilization) cannot be approved starting at 5:56am on March 18, 2019. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of post-stabilization care have not been met. Therefore, we decided that the Plan 
does not have to pay for post-stabilization care provided to the enrollee from March 18, 2019 through March 
20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services provided from April 15, 2019 through November 7, 2019.
You asked the Plan to pay for dental services. You say that you weren't informed the provider was not in-network until you were denied reimbursement. The Plan denied your request. The Plan says out-of-network dental services are not covered benefits.
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, out-of-network dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for dental services provided from April 15, 2019 through November 7, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel rendered on February 26, 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 the claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that the panel must be billed with procedure 
code 81479. 
 
The file shows that the panel was not billed with code 81479 but as a panel of codes. 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 panel rendered on February 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation and the panoramic x-ray provided 
on March 11, 2020. 
 
You asked the Plan to pay for the limited oral evaluation and the panoramic x-ray. You say that there was an 
injury to the jaw when you fell. You say that you should have a $15 copayment. The Plan denied your request. 
The Plan says payment cannot be issued for services performed by an out-of-network provider or a provider 
that does not participate with Medicare. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These services were also provided by a provider who 
is not eligible to participate in Medicare. These are dental services that are not covered or paid for by Medicare. 
Therefore, we decided that the Plan does not have to pay for the limited oral evaluation and the panoramic x-
ray provided on March 11, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray (74221) provided March 9, 2020. 
 
You asked the Plan to pay for the x-ray. You say that the services were medically necessary. The Plan denied 
your request. The Plan says the services were out-of-network and were not pre-authorized or emergent. There 
were network providers available. 
 
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 services at issue in this appeal. The Plan did not pre-approve the service at issue. 
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 an x-ray (74221) provided March 9, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the development of cognitive skills to improve attention, 
memory, problem solving services coded G0515 provided from February 4, 2019 to February 11, 2019. 
 
You asked the Plan to pay for the development of cognitive skills to improve attention, memory, problem 
solving services. You say that you would like the plan to reconsider their denial. The Plan denied your request. 
The Plan says the services rendered are not a covered benefit. 
 
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, we have confirmed that code G0515 
for the development of cognitive skills to improve attention, memory, problem solving services has a bundled 
relationship with code 92526 and cannot be paid as billed. This code cannot be paid as a separate line item. 
Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan 
does not have to pay for the development of cognitive skills to improve attention, memory, problem solving 
services coded G0515 provided from February 4, 2019 to February 11, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a brochoscopy (31645) provided on January 29, 2020. 
 
You asked the Plan to pay for a brochoscopy. You say that the records for this service were submitted. The 
Plan denied your request. The Plan says there is a more appropriate code for the service performed. 
 
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 31645 is bronchoscopy, rigid or flexible, including 
fluoroscopic guidance, when performed; with therapeutic aspiration of tracheobronchial tree, initial. 
 
We find that CPT code 31645 is not supported in the medical record. Specifically, the submitted medical 
records do not include documentation showing that therapeutic aspiration was performed. Based on this 
information, we decided that Medicare rules for coverage of a brochoscopy have not been met. Therefore, we 
decided that the Plan does not have to pay for a brochoscopy (31645) provided on January 29, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for betamethasone acetate 3 mg and betamethasone sodium 
phosphate 3 mg. 
 
You asked the Plan to pay for betamethasone acetate 3 mg and betamethasone sodium phosphate 3 mg. You 
say that the Plan should pay this claim. The Plan denied your request. The Plan says code J0702 remains not 
supported in the documentation submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that 3 units of CPT code J0702 are not supported in the medical record. The medical record only 
supports 2 units of CPT code J0702. Based on this information, we decided that Medicare rules for coverage of 
betamethasone acetate 3 mg and betamethasone sodium phosphate 3 mg have not been met. Therefore, we 
decided that the Plan does not have to pay for betamethasone acetate 3 mg and betamethasone sodium 
phosphate 3 mg provided on February 6, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient therapy provided by an out-of-network provider 
from March 23, 2020 through March 31, 2020. 
 
You asked the Plan to pay for outpatient therapy. You say that you were not informed the provider was no 
longer in-network. You say that the claim should be overturned and paid. The Plan denied your request. The 
Plan says prior authorization was not requested for the enrollee to receive out-of-network services. 
 
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 outpatient therapy provided by an out-of-network 
provider from March 23, 2020 through March 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a Medicare Part B prescription drug 
provided on October 8, 2019. 
 
You asked the Plan to waive the coinsurance for a Medicare Part B prescription drug. You say that you would 
not have received the injection if you had known the cost ahead of time. 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay $201.24, which is less than the 20% coinsurance for a Medicare Part B 
prescription drug. A Medicare Part B prescription drug falls within the Medicare Part B prescription drugs 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the coinsurance for a Medicare Part B prescription 
drug provided on October 8, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown for tooth #11 (D2740). 
 
You asked the Plan to pre-approve a crown for tooth #11. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has 
not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a crown for tooth #11. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found restorative dental services, including crowns, are covered when medically necessary. 
The imaging available in the case file does not demonstrate significant dental caries, worn dentition, or 
cracking of the tooth. 
 
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 crown for tooth #11 have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a crown for tooth #11 (D2740).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Budesonide-Formoterol Fumarate (J3535). 
 
You asked the Plan to pre-approve the Budesonide-Formoterol Fumarate. The Plan denied your request. The 
Plan says this drug is not covered for your condition by Medicare Part B. 
 
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 Budesonide-Formoterol 
Fumarate (J3535).  
 
Benefits for the Budesonide-Formoterol Fumarate may be available under Medicare Part D. Contact the Plan 
that administers Part D benefits for further information concerning any benefits and appeal rights.