Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for CT of the head or brain (70450) provided on May 13, 2020. 
 
You asked the Plan to pay for the CT scan. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says that CPT code 70450-26 is a column II procedure to 
the column I procedure, 70496, billed by a different provider. 
 
The Plan must follow Medicare rules. Medicare rules say that all line items for the same beneficiary, same NPI, 
and same date of service shall be subject to NCCI procedure-to-procedure (PTP) edits. 
 
We find that CPT code 70450 is supported in the record. Specifically, these codes were billed by providers 
with different NPIs. It is not appropriate to apply NCCI edits for claims with different NPIs. Based on this 
information, we decided that Medicare rules for coverage of the CT scan have been met. Therefore, we decided 
that the Plan has to pay for CT of the head or brain (70450) provided on May 13, 2020.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on May 12, 2020. 
 
You asked the Plan to pay for the 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 above, 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 May 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on June 
26, 2020. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you are not satisfied with 
the level of care you received because you needed to visit an urgent care facility later. The Plan denied your 
request. The Plan says the copayment you are being charged is correct. 
 
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 $40 
copayment for provider and professional services in an in-network specialist's office.  
 
You have been asked to pay a $40 copayment for a specialist office visit. A specialist office visit falls within 
the physician/practitioner services, including doctor's office visits, 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 a specialist office visit provided on June 26, 2020.  
 
Your complaint about needing to make a visit to an urgent care facility is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 7, 2019 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for laboratory tests. You say that you have no direct encounter with the enrollee; 
therefore, you have no means of knowing if prior authorization is required. The Plan denied your request. The 
Plan says the denial of payment for these services is correct, because this provider is out-of-network with the 
Plan and the ordering provider is also out-of-network with the Plan. 
 
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 medical services provided on October 7, 2019 
by an out of network (OON) provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services rendered on February 18, 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 that the services do not meet coding standards. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan states that the services do not meet coding standards but does not 
provide any further explanation of the denial reason. There is no documentation or Medicare rules presented to 
support that the services are not payable as billed. Therefore, we decided that the Plan has to pay for the 
laboratory services rendered on February 18, 2020.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on May 11, 
2020. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the charges 
because you could have had a family member transport 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 $260 
copayment for ambulance services.  
 
You have been asked to pay a $260 copayment for ambulance services. Ambulance services fall 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 May 11, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PET scan coded 78815 provided on March 16, 2020. 
 
You asked the Plan to pay for the PET scan. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services billed are not payable. 
 
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 78815 is positron emission tomography (PET) with 
concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization 
imaging; skull base to mid-thigh. 
 
We find that CPT code 78815 is not supported in the medical record. Specifically, this code was not reported 
with an appropriate diagnosis code. PET procedures performed to inform the subsequent treatment strategy of 
cancerous tumors (modifier PS) must be reported with an appropriate diagnosis. Based on this information, we 
decided that Medicare rules for coverage of the PET scan have not been met. Therefore, we decided that the 
Plan does not have to pay for the PET scan coded 78815 provided on March 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the parenteral nutrition provided to the enrollee from April 
13, 2020 to April 19, 2020. 
 
You asked the Plan to pay for these services. You say that the parenteral nutrition was medically necessary. 
The Plan denied your request. The Plan says that the billed services were not supported. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery. The proof of delivery submitted did not include a 
signature confirming this was delivered to the enrollee. The record shows that the Plan made several attempts 
to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to 
pay for the parenteral nutrition provided to the enrollee from April 13, 2020 to April 19, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Abraxane. 
 
You asked the Plan to pre-approve Abraxane. You say that Abraxane is medically necessary. The Plan denied 
your request. The Plan says step therapy criteria are not met in this case. 
 
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 Abraxane. Our reviewer says that 
Abraxane is not supported for coverage in this case. Our physician reviewer found the documentation does not 
support a history of non-small cell lung cancer. Documentation does not discuss previous treatment, 
contraindication, or hypersensitivity to Taxol or Taxotere. Step therapy, as outlined by the plan, requires these 
medications be trialed or documentation of hyper-sensitivity to these conventional treatments. Without the 
support of the documentation, Abraxane is not approved as step therapy criteria is not met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Abraxane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Abraxane.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 testing provided on March 24, 2020. 
 
You asked the Plan to pay for genetic testing. You say that the enrollee's treating physician ordered this testing 
to determine if there was a more effective therapy for the enrollee's condition. 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 March 24, 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 March 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve replacement batteries for a power scooter. 
 
You asked the Plan to pre-approve replacement batteries for a power scooter. You say that the items are 
necessary. The Plan denied your request. The Plan says Medicare did not pay for the base item initially. 
Therefore, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that in the case of repairs to a beneficiary-owned 
DMEPOS item, if Medicare paid for the base item initially, medical necessity for the base item has been 
established.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of replacement batteries for a power scooter have not been met. Therefore, we decided that the Plan 
does not have to pre-approve replacement batteries for a power scooter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on January 21, 2020. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says services 
without a valid medical diagnosis related to the health of the enrollee are not a covered benefit. 
 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The testing at issue in this appeal was requested for screening purposes. The documentation does not show that 
the results of the testing would be used to determine a specific diagnosis or treatment strategy. Medicare does 
not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
lab testing provided on January 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office outpatient visit (99214) provided on March 17, 
2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that medically necessary services were rendered in good 
faith. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent 
services rendered by an out-of-network provider. 
 
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 office outpatient visit (99214) provided on 
March 17, 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 wound care services provided on December 2, 2019, 
December 13, 2019 and December 26, 2019. 
 
You asked the Plan to pay for the wound care services. The Plan denied your request. The Plan says the Plan 
requires utilization of network providers when possible and available, and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented. 
 
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 
wound care. 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 wound care services provided on December 2, 2019, December 
13, 2019 and December 26, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the professional component (PC) of the magnesium testing 
provided on February 26, 2020 billed with code 83735-26. 
 
You asked the Plan to pay for the magnesium testing PC. You say that this should be paid as medically 
necessary. The Plan denied your request. The Plan says this code is not payable for only a PC. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
CPT code 83735 has a status indicator of "X" on the Physician Fee Schedule, meaning it is statutorily excluded. 
It is noted that the concept of a professional/technical component does not apply. This code is not shown to be 
payable for the PC only based on information from the Clinical Laboratory Fee Schedule. Based on this 
information, we decided that Medicare rules for coverage of the magnesium testing PC have not been met. 
Therefore, we decided that the Plan does not have to pay for the professional component (PC) of the 
magnesium testing provided on February 26, 2020 billed with code 83735-26.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on April 14, 2020. 
 
You asked the Plan to pay for the orthosis. The Plan denied your request. The Plan says the records do not 
support the service billed. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain valid proof of delivery for the orthosis provided in this case. The record shows that 
the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided 
that the Plan does not have to pay for the lumbar-sacral orthosis provided on April 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab work, a CT scan, an outpatient surgery 
and a specialist office visit provided by a participating provider on June 8, 2020, to June 24, 2020. 
 
You asked the Plan to waive the copayment for lab work, a CT scan, an outpatient surgery and a specialist 
office visit. You say that you do not agree with all of these charges. You say that there was no reason to have 
all of these services done. The Plan denied your request. The Plan says the correct copayments have been 
applied. 
 
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 an $8 
copayment for outpatient diagnostic tests/lab, a $250 copayment, for outpatient diagnostic tests/diagnostic 
imaging a $350 copayment for outpatient surgery and a $45 copayment for outpatient surgery and 
physician/practitioner services/specialist.  
 
You have been asked to pay an $8 copayment for lab work, a $205.78 copayment for a CT scan, a $342 
copayment for an outpatient surgery and a $37 copayment for a specialist office visit. The total amount you are 
being asked to pay is $600.78 ($8 + $8 + $205.78 + $342 + $37 = $600.78). Lab work falls within the 
outpatient diagnostic tests/lab benefit category. A CT scan falls within the outpatient diagnostic tests/diagnostic 
imaging benefit category. An outpatient surgery falls within the outpatient surgery benefit category and a 
specialist office visit falls within the physician/practitioner services/specialist 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 lab work, a CT scan, an outpatient surgery and a specialist office 
visit provided by a participating provider on June 8, 2020, to June 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the podiatry services provided on June 9, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that the provider is the only doctor that can treat the 
enrollee. The Plan denied your request. The Plan says multiple podiatrists in network to provide the 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 services at issue in this appeal. The Plan did not pre-approve the services at 
issue. We found no exception that would require the Plan to pay for these OON services. Therefore, we decided 
that the Plan does not have to pay for the podiatry services provided on June 9, 2020 by an out of network 
(OON) provider.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the extraction. We decided that the Plan does not have to pay for the 
comprehensive oral evaluation.  
 
You asked the Plan to pay for the extraction and comprehensive oral evaluation. You say that this was an 
emergency extraction. The Plan says that the enrollee does not have a supplemental dental benefit plan. 
 
We decided that the Plan has to pay for the extraction.  
 
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. The rules say that the health 
plan must provide the enrollee with a clear and accurate description of the benefits offered under the Plan. 
 
The Evidence of Coverage clearly shows that the enrollee has dental benefits, and extractions are listed as a 
 
 
covered benefit. The enrollee reasonably believed the extraction would be covered because contract does not 
clearly list any covered, or non-covered, extraction codes. Therefore, we decided that the Plan has to pay for 
the extraction.  
 
We also decided that the Plan does not have to pay for the comprehensive oral evaluation. 
 
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. This service is a preventive dental service, and the contract clearly 
states that preventive services are not covered. Therefore, we decided that the Plan does not have to pay for the 
comprehensive oral evaluation. 
 
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.