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

 
We decided that the Plan has to pay for Cxbladder testing provided on May 12, 2020. 
 
You asked the Plan to pay for genetic testing. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says that the denial of payment for this testing is correct, because this testing is not 
covered. 
 
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. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a 
contract provider are considered approved by the plan unless notice is provided that the services will not be 
covered. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not specify whether the ordering physician was in-network or out-
of-network with the Plan. The documentation submitted does not include prior notice from the Plan that this 
testing would not be covered. This testing is not explicitly excluded from Medicare coverage. Without this 
information, we cannot determine whether the lab order made constituted plan-directed care. Therefore, the 
Plan has not shown that its decision to deny payment for this testing is justified or correct according to 
Medicare rules. Therefore, we decided that the Plan has to pay for Cxbladder testing provided on May 12, 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a routine eye examination provided on May 12, 2020. 
 
You asked the Plan to pay for eye exam. You say that you were told you need to see this provider and you hope 
the Plan will pay the provider. The Plan denied your request. The Plan says the denial of payment for this 
service is correct, because the benefit for routine eye exam was exhausted at the time this visit was performed. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers one routine eye examination per year. 
 
We looked at the file and the Plan's rules. You received a routine eye examination on March 23, 2020; 
therefore, the benefit for routine eye exam was exhausted at the time this service was performed. Based on this 
information, we decided that the Plan's rules for coverage of eye exam have not been met. Therefore, we 
decided that the Plan does not have to pay for a routine eye examination provided on May 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation, bitewing x-rays and prophylaxis 
provided on February 17, 2020. 
 
You asked the Plan to pay for the periodic oral evaluation, bitewing x-rays and prophylaxis. You say that you 
have always been reimbursed since you started with the Plan. You say that if you knew about the change you 
could have made other plans. The Plan denied your request. The Plan says payment cannot be issued for 
services performed by a provider that has opted out of 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 periodic oral evaluation, bitewing x-rays and prophylaxis provided on February 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chest x-ray (71046) provided March 27, 2020. 
 
You asked the Plan to pay for the chest x-ray. You say that the x-ray was medically necessary. The Plan denied 
your request. The Plan says the claim is a duplicate. 
 
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 71046 is not supported in the medical record. Specifically, the record shows the claim is 
a duplicate. Based on this information, we decided that Medicare rules for coverage of the chest x-ray have not 
been met. Therefore, we decided that the Plan does not have to pay for a chest x-ray (71046) provided March 
27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services you received from March 6, 2019, 
to October 22, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not 
covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the chiropractic services you received from March 6, 2019, to October 
22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a second opinion provided on January 31, 2019 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for a second opinion. You say that you wanted to see an out-of-network provider for 
a second opinion. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan 
says that there are in-network providers available for these 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 a second opinion provided on January 31, 2019 by 
an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing services provided on March 25, 2019 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for skilled nursing services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 
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 skilled nursing services provided on March 25, 
2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiac device monitoring services(93295) provided on May 
10, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the cardiac monitoring services. You say that your services were rendered in the 
hospital setting and in good faith that the hospital complied with all authorization requirements. The Plan 
denied your request. The Plan says enrollee's must receive their medical services from an in-network provider 
with the exception being urgent or emergent services. The plan says that non-emergent services with non-
contracted providers require prior authorization before services being rendered. 
 
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 cardiac device monitoring services(93295) 
provided on May 10, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthotics rendered on March 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 the services are not covered. 
 
The Plan must follow Medicare rules. The reasonable useful lifetime of durable medical equipment is 
determined through program instructions. In the absence of program instructions, A/B MACS (B) may 
determine the reasonable useful lifetime of equipment, but in no case can it be less than 5 years.  
 
We looked at the file and Medicare rules. The file shows that the enrollee previously received a lumbar-sacral 
orthosis on September 25, 2019 and an ankle-foot orthosis on July 9, 2015. These items have not outlived the 
five year reasonable lifetime period and are not irreparably damaged. 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 orthotics rendered on March 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nitrous oxide services rendered on May 5, 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 services are not covered. 
 
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 
nitrous oxide services rendered on May 5, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on January 6, 2020. 
 
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the claim 
was submitted 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 drug testing services have not been 
met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on January 
6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services provided on February 11, 2019 to May 
16, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for outpatient services. You say that you think that Medicare should pay for some of 
this. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the 
member's primary care physician did not refer these 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 services provided on February 11, 2019 
to May 16, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99309, 99310), 
initial nursing facility care, per day (99306), and advanced care planning (99497) rendered by the out of 
network (OON) providers from January 30, 2020 to February 6, 2020. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by out of network 
providers, 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 providers in this case are not network providers 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 services. Therefore, we decided that the Plan 
does not have to pay for the subsequent nursing facility care, per day (99309, 99310), initial nursing facility 
care, per day (99306), and advanced care planning (99497) rendered by the out of network (OON) providers 
from January 30, 2020 to February 6, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electroencephalogram (95822) provided December 19, 
2019. 
 
You asked the Plan to pay for an electroencephalogram. You say that you would like reconsideration based on 
the medical records provided. The Plan denied your request. The Plan says the billed code cannot be verified. 
 
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 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 an electroencephalogram. Our reviewer says 
that the billed service is not supported. Our physician reviewer found the medical records provided do not 
include documentation of an Electroencephalogram (EEG); recording in coma or sleep only being performed 
on December 19, 2019, therefore this service cannot be verified. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electroencephalogram have not been met. Therefore, we decided that the 
Plan does not have to pay for an electroencephalogram (95822) provided December 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ankle orthosis (L1971), lumbar-sacral orthosis (L0650), 
plastic foot (L3170), knee orthosis (L1851), suspension sleeve (L2397), shoulder elbow wrist hand orthosis 
(L3960) and wrist hand orthosis (L3916) provided on March 16, 2020. 
 
You asked the Plan to pay for the orthoses. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the documentation submitted did not include an 
itemized shipping/billing invoice to indicate the specific supplies or proof of delivery for the billed date of 
service. 
 
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 for the supplies provided in this case. The documentation 
submitted does not include an itemized shipping/billing invoice or a proof of delivery for the date of service. 
To note, the delivery ticket included is for a different date than what was billed. 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 an ankle orthosis (L1971), lumbar-sacral orthosis (L0650), plastic foot (L3170), 
knee orthosis (L1851), suspension sleeve (L2397), shoulder elbow wrist hand orthosis (L3960) and wrist hand 
orthosis (L3916) provided on March 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on 
February 21, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not indicate services are necessary for treatment of the 
enrollee's condition. 
 
The rules say for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. When conducting a review of a 
covered DME item, ordered by a physician, the contractor shall ensure that the physician saw the beneficiary 
and conducted a face-to-face assessment. Therefore, we decided that the Plan does not have to pay for a 
lumbar-sacral orthosis (L0650) provided to the enrollee on February 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral periapical, each additional x-ray (D0230) provided 
April 9, 2020. 
 
You asked the Plan to pay for the x-ray. You say that you lost a filling and was able to get an emergency 
appointment. He took the x-ray to be assured it would be possible to delay the filling, which has been 
rescheduled. The Plan denied your request. The Plan says this service exceeds the benefit frequency limitation. 
 
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 plan allows 1 intraoral x-
ray is allowed per year. The plan has already approved payment for 1 intraoral x-ray for this date of service. 
 
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 intraoral 
periapical, each additional x-ray (D0230) provided April 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the injectable Part B drugs you received 
on May 5, 2020. 
 
You asked the Plan to waive the cost sharing for the drugs. You say that you should not have to pay this much 
for these services.  You say that you shouldn't to pay an administration charge at. You also say that you don't 
understand why you must pay the remaining balance for the drugs you received. The Plan denied your request. 
The Plan says it has reduced the cost sharing due for the administration charge, but the coinsurance for the Part 
B drugs you received was applied 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 20% 
coinsurance for Medicare-covered Part B drugs.  
 
You have been asked to pay 20% coinsurance for the drugs.  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 cost sharing 
for the injectable Part B drugs you received on May 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on March 5, 2020. 
 
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services 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 subsequent nursing facility care provided on March 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for orthotic items and supplies provided on March 19, 2020. 
 
You asked the Plan to pay for orthotic items and supplies. You say that you are appealing with records. The 
Plan denied your request. The Plan says the denial of payment for these items is correct, because the 
documentation submitted does not support the date of service billed on this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the Plan sufficient 
information to determine whether payment is due for a claim. The documentation submitted by the provider 
must corroborate the medical record. 
 
We looked at the file and Medicare rules. The documentation submitted does not include valid proof of 
delivery for the date of service billed on this claim. Without this information, you have not submitted sufficient 
information to the Plan to justify payment of the claim as billed. Based on this information, we decided that 
Medicare rules for coverage of orthotic items and supplies have not been met. Therefore, we decided that the 
Plan does not have to pay for orthotic items and supplies provided on March 19, 2020.