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

We decided that the Plan does not have to pay for the drug testing services provided on September 24, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. We looked at the file and Medicare rules. The documentation shows that the services in question were billed 
with POS code 81. However, the records indicate that the specimen was collected in an office setting, which 
would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. 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 drug testing services provided on September 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive exam, bitewing x-rays, panoramic x-ray, 
and two periapical x-rays provided on March 2, 2021 by an OON provider. 
 
You asked the Plan to pay for the comprehensive exam, bitewing x-rays, panoramic x-ray, and two periapical 
x-rays. You say that your coverage was described to you as comprehensive, and you thought it was safe to 
assume all or nearly all dental services would be covered. You also say that the allowed amounts were not 
explained to you. The Plan denied your request. The Plan says all services on the claim have been paid at 100% 
of the allowed amount. The Plan also says that you are responsible for the difference between the provider's 
submitted, approved dental fees and the allowed amounts from the Plan's dental fee schedule. 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, you are responsible for the difference 
between the billed amount and allowed amount for services received OON. Therefore, we decided that the Plan 
does not have to pay for the comprehensive exam, bitewing x-rays, panoramic x-ray, and two periapical x-rays 
provided on March 2, 2021 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Zoster vaccine and administration provided on October 20, 2020.
You asked the Plan to pay for immunization administration (90471, 90472), Zoster (shingles) vaccine (90750). You say that the Plan should pay this claim. The Plan denied your request. The Plan says this vaccine is not a Medicare covered benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Zoster (shingles) vaccine (90750). The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the Zoster
(shingles) vaccine (90750). Therefore, we decided that the Plan does not have to pay for the Zoster vaccine and administration provided on October 20, 2020.
Benefits for immunization administration (90471, 90472), Zoster (shingles) vaccine (90750) 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve aquatic therapy. 
 
You asked the Plan to pre-approve the aquatic therapy. You say that you would like aquatic therapy to help 
with the pain in your knees, your back, and in your joints. The Plan denied your request. The Plan says there is 
no documentation/rationale that aquatic therapy is medically necessary as opposed to standard land-based 
therapy. 
 
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 the aquatic therapy. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the requested aquatic therapy is not generally accepted as specific and 
effective therapy for your condition as the documentation does not reveal that you are unable to tolerate land- 
based therapy. The requested aquatic therapy exceeds your medical need at this time and therefore is not 
medically necessary per Social Security Act, Section 1862 (a)1(A) and the 42 CFR ?411.15(k) as Medicare 
does not pay for any items or services that are not reasonable and necessary for the diagnosis or treatment of 
illness or injury or to improve the functioning of a malformed body member. There is no evidence that you 
were unable to tolerate land-based therapy in the past and there is no evidence of a trial of recent land based 
physical therapy. The documentation does not reveal extenuating factors on a physical exam that would 
contraindicate a trial of land-based physical therapy. Aquatic therapy, at this time, is not medically necessary to 
maintain your current condition or to prevent or slow further deterioration. 
 
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 aquatic therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve aquatic therapy.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve multiple CT scans (CPT code(s): 74175, 72191, 71275, 71250, 74176, 74150, 72192), for the enrollee.
You asked the Plan to pre-approve the CT scans. You say that the enrollee has endovascular AAA and needs an arterial and Venus check for endolics. The Plan denied your request. The Plan says there is no additional documentation received to support imaging studies requested. The Plan states you ordered several test to be done at the same time and you did not give the plan a specific reason why you need all these tests at the same time.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CT scans have not been met. There are no medical records provided to verify with the services are needed. Therefore, we decided that the Plan does not have to pre-approve multiple CT scans (CPT code(s): 74175, 72191, 71275, 71250, 74176, 74150, 72192), for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lucentis (J2778) for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your
request. The Plan says there is no indication that Bevacizumab would likely be less effective and/or cause
adverse effects.
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 the drug. Our reviewer says that the
requested drug is not medically reasonable or necessary. Our physician reviewer found the plan requires a trial
of drug Bevacizumab before they will approve the requested drug. In this case, the enrollee has not tried and
failed the required drug. There is no documentation provided indicating that the Plan's required drug 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 the drug have not been met. Therefore, we decided that the Plan does not have
to pre-approve Lucentis (J2778) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for debridement provided from February 10, 
2021, to March 12, 2021. 
 
You asked the Plan to waive the copayments for debridement. You say that you thought that you would owe a 
lesser copayment for minor surgeries and this is a financial strain on you. 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 $150 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
You received debridement at an outpatient surgical facility from February 10, 2021, to March 12, 2021, for a 
total of 3 visits. Debridement is considered an outpatient surgical procedure. Therefore, you are responsible to 
pay a $150 copayment per each service. The total amount you owe is: $150 (copayment) x 3 (debridement services) = $450.  
 
You have been asked to pay the total copayment amount of $450 for debridement. Debridement 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 copayments for debridement provided from 
February 10, 2021, to March 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for a limited oral evaluation (D0140), and an extraction (D7210) provided on October 23, 2020.
You asked the Plan to pay an additional amount for a limited oral evaluation, and an extraction. You say that you want the Plan to pay an additional amount towards the services. The Plan denied your request. The Plan says the provider was paid at the Medicare allowed rate therefore no additional payment can be made.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a limited oral evaluation, and an extraction have not been met. Specifically, the allowed amount of these services for an out-of-network provider were paid by the plan. Therefore, we decided that the Plan does not have to pay an additional amount for a limited oral evaluation (D0140), and an extraction (D7210) provided on October 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on February 24, 2021.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are
not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.
The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab
services provided on February 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation provided indicating medical necessity for LTACH 
services. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where she is currently receiving 
care. There are no services available at the LTACH that the enrollee requires that are not available at the health 
care setting being offered by the health plan. The requested LTACH services are not medically necessary, 
reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and 
effectively only on an inpatient basis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for reimbursement towards a tennis club membership.
You asked the Plan to pay for the reimbursement. You say that a tennis club fits under the description of the sorts of services covered by the wellness benefit. The Plan denied your request. The Plan says membership fees towards a non-qualified health club were paid.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits only towards qualified health clubs or fitness facilities. The Plan's rules for coverage of gym benefits have not been met because the plan specifically excludes tennis for the wellness allowance. Therefore, we decided that the Plan does not have to pay for reimbursement towards a tennis club membership.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit (S9083) provided on 
March 20, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $65 
copayment for each Medicare-covered urgent care facility visit.  
 
You have been asked to pay a $65 copayment for the urgent care facility visit provided. 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 urgent care visit (S9083) provided on 
March 20, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the unclassified drugs (J3490 KP and J3490 KQ 59)
provided on March 23, 2021.
You asked the Plan to pay for the unclassified drugs. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says vitamin injections into the nerve and
muscoskeletal structures are not a Medicare 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.
We find that CPT code J3490 KP and J3490 KQ 59 is not supported in the medical record. Specifically, the
multiple drug codes reported on this claim refer to a pre-filled compounded drug/vitamin syringe. The rules
require that any compounded drug be billed using the not otherwise classified code J7999. As this compounded
drug was not billed properly, payment cannot be made. Therefore, we decided that the Plan does not have to
pay for the unclassified drugs (J3490 KP and J3490 KQ 59) provided on March 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for chiropractic services provided on September 9, 2020.
You asked the Plan to pay for chiropractic services. You say that this claim should be paid by the Plan. The Plan denied your request. The Plan says services it covers 30 visits per year and that benefit was exhausted as of the visit on August 17, 2020.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine. The Plan contract states up to 30 visits are covered. The Plan provided records showing payment of 30 visits prior to September 9, 2020. This benefit was exhausted. Therefore, we decided that the Plan does not have to pay for chiropractic services provided to the enrollee on September 9, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the cystourethroscopy procedure you had at 
an outpatient hospital facility on December 15, 2020. 
 
You asked the Plan to waive the copayment for the cystourethroscopy procedure. You say that this service was 
covered fully in the past. The Plan denied your request. The Plan says you were charged this copayment 
correctly.  The Plan says that it has adjusted your claim so that you are only responsible for a $35 copayment 
for this service. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for diagnostic procedures and tests.  
 
You have been asked to pay a $35 copayment for the cystourethroscopy procedure. The cystourethroscopy procedure falls within the diagnostic procedures and tests 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 cystourethroscopy procedure you had at an outpatient hospital facility on 
December 15, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a GeneDose panel (81230, 81240, 81241, 81291) provided on April 13, 2021.
You asked the Plan to pay for a GeneDose panel. You say that this is supported by the records. The Plan denied your request. The Plan says this was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. If a laboratory assays 2 or more genes in a patient in parallel, then those 2 or more genes will be considered part of the same panel.
A panel constitutes a single procedural service, so 1 code must be submitted for the panel. We find that CPT codes 81230, 81240, 81241, and 81291 are not supported in the medical record. Specifically, these codes were used to report a panel, which should be billed with a single code. Based on this information, we decided that Medicare rules for coverage of a GeneDose panel have not been met. Therefore, we decided that the Plan does not have to pay for a GeneDose panel (81230, 81240, 81241, 81291) provided on April 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultraviolet light therapy unit purchased for the home on
December 28, 2020.

You asked the Plan to pay for this equipment. You say that your physician was treating you in the office with
ultraviolet light, but the distance was too far to travel. You state that you negotiated a good price for this
equipment and believe the Plan should cover its purchase. The Plan denied your request. The Plan says you did
not have prior authorization for this equipment and an at home UV light therapy unit is not covered for your
condition.

The Plan must follow Medicare rules. Medicare only covers a UV light therapy cabinet for home use for
generalized intractable psoriasis and only when facility treatments are not available. The medical records did
not confirm this is your diagnosis. The Plan contract states that durable medical equipment may require prior
authorization. This type of equipment would require prior authorization which was not given by the Plan. You
obtained this equipment without following the Medicare coverage rules or the Plan contract rules. Therefore,
we decided that the Plan does not have to pay for an ultraviolet light therapy unit purchased for the home on
December 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the arthrocentesis procedure and related services you received at an outpatient hospital facility on May 12, 2021.
You asked the Plan to waive the copayment for the arthrocentesis procedure. You say that you believe these services were done in a doctor's office, not an outpatient hospital. The Plan denied your request. The Plan says you were charged this copayment 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 services at an outpatient hospital facility. You have been asked to pay a $250 copayment for the arthrocentesis procedure. The billing records show that the facility where you received these services is considered an outpatient hospital facility. The arthrocentesis procedure falls within the services at an outpatient hospital facility 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 arthrocentesis procedure and related services you received at an outpatient hospital facility on May 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extraction (D7210) provided on December 23, 2020.
You asked the Plan to pay for the dental service. You say that your dentist does not pull teeth anymore. You also say that you had to see an oral surgeon to get your tooth removed. The Plan denied your request. The Plan says you pay 100% for Class 3 Major Service, including surgical extractions.
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, surgical extractions are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the surgical extraction (D7210) provided on December 23, 2020.