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

 
We decided that the Plan does not have to pay for the FoundationOne CDx testing provided on December 4, 
2018. 
 
You asked the Plan to pay for the FoundationOne CDx testing. You say that the provided FoundationOne CDx 
testing provided was medically necessary. The Plan denied your request. The Plan says the enrollee does not 
meet criteria for the provided FoundationOne CDx testing. 
 
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 pay for the FoundationOne CDx testing. Our 
reviewer says that the enrollee does not meet criteria for the provided FoundationOne CDx testing. Our 
physician reviewer found the enrollee is with stage IIIc uterine cancer and what appears to be new lung 
primary. The file does not contain evidence for relapsed, refractory metastatic or stage III lung cancer. The 
criteria for the FoundationOne CDx testing would be met if there were documentation showing recurrent 
uterine cancer; however, this was not provided. The documentation is insufficient to make a determination. 
 
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 FoundationOne CDx testing have not been met. Therefore, we decided that 
the Plan does not have to pay for the FoundationOne CDx testing provided on December 4, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlab services provided to the enrollee on November 5, 2019 and billed under codes 80307 and G0480.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says the place of service code reported on the claim is invalid.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, the claim submitted cannot be paid due to an issue with the place of service or POS code. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay forlab services provided to the enrollee on November 5, 2019 and billed under codes 80307 and G0480.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a drug test provided on May 12, 2020. 
 
You asked the Plan to pay for the drug test. 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 
drug test. 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 a drug test provided on May 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the gingivectomy or gingivoplasty and impacted tooth 
removal. 
 
You asked the Plan to pre-approve the gingivectomy or gingivoplasty and impacted tooth removal. The Plan 
denied your request. The Plan says the 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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
gingivectomy or gingivoplasty and impacted tooth removal.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection services with CPT code 64455 provided on 
April 7, 2020. 
 
You asked the Plan to pay for the injection services with CPT code 64455. You say that you would like the 
Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 64455 is 1. You billed 2 units of this code, exceeding the MUE. Based on 
this information, we decided that Medicare rules for coverage of the injection services with CPT code 64455 
have not been met. Therefore, we decided that the Plan does not have to pay for the injection services with CPT 
code 64455 provided on April 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.The rules say that Medicare will pay for durable medical equipment that is mainly used to serve a medical purpose. Items such as hospital beds, respirators, wheelchairs and crutches are examples of equipment that are clearly used for medical purposes. Medicare will not pay for:1. Equipment that is primarily and customarily used for nonmedical purposes. Examples include air conditioners, humidifiers, dehumidifiers and electric air cleaners;2. Equipment used for a patient's comfort or for the convenience of a person caring for the patient. Examples include elevators, stairway elevators, physical fitness equipment and self-help devices such a grab bars. You can find these rules in the Medicare Benefit Policy Manual, Chapter 15, Section 110.1.If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oxygen equipment billed to the enrollee. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the documentation submitted did not include an itemized shipping/billing invoice to 
indicate the specific supplies, or proof of delivery. 
 
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 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 oxygen equipment billed to the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on February 25, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
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 the laboratory services are not supported in the medical record. Specifically, the documentation 
submitted did not support that the laboratory testing was performed with blood sampling. The lab requisition 
shows a urine sample was collected. Based on this information, we decided that Medicare rules for coverage of 
the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the 
laboratory services provided on February 25, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that the patient was on Fosamax for over a year and has also 
finished one year of therapy of evenity. The patient really needs Prolia to help build bone back. The Plan 
denied your request. The Plan says we cover this item for treating osteoporosis only after you have tried and 
failed medications such as IV or oral bisphosphonate such as reclast or fosamax or combination of oral and IV 
bisphosphonates for a period of 24 months. The information we received shows that you have not tried a 
bisphosphonate drug. 
 
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 Prolia. Our reviewer says that the item 
is not medically necessary. Our physician reviewer found the Plan requires a trial of one drug, Reclast or 
Fosamax (bisphosphonate therapy), before the requested drug will be approved. In this case, the patient has not 
tried and failed the required drug(s).  
  
There is no documentation provided indicating that the plan?s required drug(s) 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional vision benefits. 
 
You asked the Plan to pre-approve the additional benefits. You say that you would like to reset your benefit. 
The Plan denied your request. The Plan says the benefit has been exhausted. 
 
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 these services with a $200 allowance every two years. 
 
We looked at the file and the Plan's rules. You are requesting a reset of the benefit so that you can receive 
further services. You previously received routine eyewear services on December 27, 2018. The benefit will 
reset on December 27, 2020. Based on this information, we decided that the Plan's rules for coverage of the 
 
 
additional benefits have not been met. Therefore, we decided that the Plan does not have to pre-approve 
additional vision benefits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee. 
 
You asked the Plan to pay for the services. You say that this should be reviewed and adjudicated. The Plan 
denied your request. The Plan says there was no prior authorization 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 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 laboratory services provided to the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the electrocardiogram (EKG) you had on 
May 11, 2020. 
 
You asked the Plan to waive the copayment for the EKG. You say that you should have your full copayment 
returned. The Plan denied your request. The Plan says you were charged this copayment correctly.  The Plan 
says that because the allowed amount for the EKG ($16.15) is less than your copayment obligation, you are 
responsible for the full 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 $25 
copayment for non-radiological diagnostic services (including EKGs).  
 
You have been asked to pay a $25 copayment for the EKG. the EKG falls within the non-radiological 
diagnostic services (including EKGs) 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 electrocardiogram (EKG) you had on May 11, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for outpatient mental health care provided on 
June 26, 2020, and July 6, 2020. 
 
You asked the Plan to waive the copayments for outpatient mental health care. You say that you disagree with 
the out-of-network charges and feel that you should only owe a $35 copayment. 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 $50 
copayment for out-of-network outpatient mental health care.  
 
You received outpatient mental health care on June 26, 2020 from an out-of-network provider. Therefore, you 
are responsible to pay the $50 copayment.  
 
You received outpatient mental health care on July 6, 2020 from an out-of-network provider. Therefore, you 
are responsible to pay the $50 copayment. 
 
The total amount you owe is: $100.  
 
You have been asked to pay the total copayment amount of $100 for outpatient mental health care. Outpatient 
mental health care falls within the outpatient mental health care 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 outpatient mental health care provided on June 26, 2020, and July 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance provided on July 24, 2020. 
 
You asked the Plan to pay for the periodontal maintenance. You say that you pay an additional amount for your 
insurance, and your cleaning was not covered. You also say that your husband pays extra for his insurance, and 
his cleaning was covered. The Plan denied your request. The Plan says your plan does not cover this procedure. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
periodontal maintenance provided on July 24, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the medical services provided on February 18, 2020. 
 
You asked the Plan to pay for the services. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says that the services are not covered. 
 
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 follows these rules. 
 
You were referred for the services by a contract provider. The file does not show that the Plan provided notice 
that the services would not be covered. Under Medicare rules, this means the services is considered approved 
by the Plan. Therefore, we decided that the Plan has to pay for the medical services provided 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to reduce the copayment from $45 to $10 for a doctor's office visit (99213). 
 
You asked the Plan to reduce the copayment from $45 to $10 for a doctor's office visit. You say that the service 
charge should be $10. The Plan denied your request. The Plan says that the correct copayment was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay a $10 copayment for provider and professional services 
received at the primary care provider's office.  
 
In this case, Medicare records show that the provider from whom you received services, is a 
general practitioner. The Plan says you must pay a $45 copayment for a doctor's office visit. Based on the Plan 
contract, however, you cannot be asked to pay more than a $10 copayment for a primary care provider?s office 
visit. Therefore, we decided that the Plan has to reduce the copayment from $45 to $10 for a doctor's office 
visit (99213).  
 
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 pay for the ambulance services provided by you on May 28, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 28, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided by you on May 
28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a filling (D2394), an intraoral periapical x-ray (D0220), 
a crown repair (D2980), a filling (D2391), a crown (D2740), a surgical stent (D582), a transosteal implant 
placement (D6050), and a custom fabricated abutment (D6057). 
 
You asked the Plan to pre-approve the dental services. You say that you are on disability. You say that you 
need dental work. You say that you have had this dentist for about 10 years. The Plan denied your request. The 
Plan says the provider in this case is not a network provider. The Plan also says that care rendered by a 
provider that is not part of our supplemental dental network is 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, you need to use a provider that is 
contracted with our dental vendor to provide supplemental dental services. Therefore, we decided that the Plan 
does not have to pre-approve a filling (D2394), an intraoral periapical x-ray (D0220), a crown repair (D2980), 
a filling (D2391), a crown (D2740), a surgical stent (D582), a transosteal implant placement (D6050), and a 
custom fabricated abutment (D6057).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services provided on January 7, 2020 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for the OON psychotherapy services. You say that this should be covered. The Plan 
denied your request. The Plan says these services were provided by an OON provider without authorization 
from the Plan or a referral from the enrollee's primary care physician. 
 
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 psychotherapy services provided on January 7, 
2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee.