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

We decided that the Plan does not have to pay for lab services provided to the enrollee on January 28, 2020, 
and billed under code 88360. 
 
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 CPT code 88360 refers to immunohistochemistry (IHC). The Plan states per LCD 36353 
"Chemosensitivity profile tumor panels, regardless of whether it is performed by IHC or chromogenic in-situ 
hybridization (CISH), is not a Medicare covered service."  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare does not cover screening services or investigational services. Maximus 
was unable to verify the LCD information from which the Plan based its denial. However, Maximus was able 
to confirm this testing is not covered as a screening. The Medical records provided do not specifically indicate 
how this testing would be used to determine a specific treatment plan for the enrollee at the time of service. In 
addition, the records show other types of testing to confirm the diagnosis had previously been done. Therefore, 
this testing would not have changed the outcome of treatment. Therefore, we decided that the Plan does not 
have to pay for lab services provided to the enrollee on January 28, 2020, and billed under code 88360.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an automatic external defibrillator (K0606) on July 25, 2020.  
 
You asked the Plan to pay for the automatic external defibrillator. You say that the claim should be paid. The Plan denied 
your request. The Plan says procedure code K0606 has a Modifier "RR" and KF that must be used. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must 
report services with the appropriate CPT code. 
 
As the procedure code K0606 was billed with either an invalid or missing modifier; we find that Medicare rule for 
payment of this claim has not been met. If there was an error in the original claim submission the plan would be willing 
to review a corrected claim. If the provider determines that a billing error occurred during the initial submission of the 
denied claim, the plan would accept a submission of a corrected claim to consider services for payment. Based on this 
information, we decided that Medicare rules for coverage of the automatic external defibrillator have not been met. 
Therefore, we decided that the Plan does not have to pay for an automatic external defibrillator (K0606) on July 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing and pay for eye imaging, an office visit, and 
eye refraction provided on July 21, 2020. 
 
You asked the Plan to waive the cost-sharing and pay for eye imaging, office visit, and refraction. You say that 
you are being charged more than you were told you would be. The Plan denied your request. The Plan says the 
coinsurance amount you are being charged is correct and the denial of payment for refraction 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). The rules say that Medicare does not cover routine vision services 
and eyewear. Your contract with the Plan clearly says that you must pay 50% coinsurance for out-of-network 
 
 
eye imaging and office visit. Your contract with the Plan also says that routine vision services such as 
refraction are only covered when provided by a Plan supplemental vision network provider. The allowed 
amounts of the eye imaging and office visit total $204.76, resulting in a coinsurance amount of $102.39. 
 
You have been asked to pay 50% coinsurance for eye imaging and office visit. Eye imaging and office visit fall 
within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" and "Vision Care" benefit 
categories. 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. The 
refraction service performed is not covered by the Plan when furnished by an out-of-network provider. 
Therefore, we decided that the Plan does not have to waive the cost-sharing and pay for eye imaging, an office 
visit, and eye refraction provided on July 21, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve occupational therapy (97165) to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve occupational therapy to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria has not been met.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve occupational therapy (97165) to be provided by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room services provided on 
March 12, 2020. 
 
You asked the Plan to waive the copayment for the emergency room services. You say that you feel you should 
not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan 
denied your request. The Plan says you received emergency room services on the date of service at issue in this 
appeal. The Plan says that the correct copayment has applied per your contract with the Plan. 
 
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 $120 
copayment for Emergency care.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received emergency room 
services on March 12, 2020. You have been asked to pay a $120 copayment for the emergency room services. 
The emergency room services fall within the Emergency 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 copayment for the emergency room services provided on March 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on June 30, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the services provided. You say that the physician treated the enrollee based on 
their condition. The Plan denied your request. The Plan says there is no record of an authorization prior to 
offering 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the wound care services at issue. 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 medical services provided on June 30, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet injections (64490, 64491).
You asked the Plan to pre-approve facet injections. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that Thermal Medial Branch Radiofrequency Neurotomy is covered under specific circumstances. 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 facet injections. Our reviewer says that the services are not medically necessary. Our physician reviewer found the first set of medial branch blocks (MBBs) did not achieve the 80% or greater pain relief required. Therefore, the request is considered not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of facet injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet injections (64490, 64491).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient services were medically necessary. 
The Plan denied your request. The Plan says the enrollee's stay was consistent with observation status level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the 
patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to 
inpatient hospital care when the hospital stay does not cross two midnights or more.  
 
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 acute inpatient hospital care. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found 
the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the 
patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare 
rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to 
pay for the acute inpatient hospital care provided.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 29, 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 follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The tests at issue in this appeal, the laboratory services, were requested solely for screening purposes. Medicare 
does not cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to 
pay for the laboratory services provided on May 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown for tooth #8 (D2740). 
 
You asked the Plan to pre-approve a crown for tooth #8. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 covers crowns when the services are 
medically necessary and reasonable.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if 
the Plan was correct in denying the request to pre-approve a crown for tooth #8. Our reviewer says that the service is not 
medically necessary. Our physician reviewer found the provided records indicate that tooth #8 is missing from the dental 
arch. Given that #8 is not present, a crown would not be medically necessary for tooth #8. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's 
rules for coverage of a crown for tooth #8 have not been met. Therefore, we decided that the Plan does not have to pre-
approve a crown for tooth #8 (D2740).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided on May 6, 2020.You asked the Plan to pay forthe 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 follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The tests at issue in this appeal, the laboratory services, were requested solely for screening purposes. Medicare does not cover these tests solely for screening purposes.Therefore, we decided that the Plan does not have to pay forthe laboratory services provided on May 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids provided on June 4, 2020.
 
You asked the Plan to pay for the hearing aids. You say that most providers were closed due to the COVID-19 
shutdown and this provider was the only local provider open. The Plan denied your request. The Plan says 
hearing aids must be supplied by the Plan's hearing network provider.
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for 
hearing aids only when provided by the Plan's hearing network vendor.
 
We looked at the file and the Plan's rules. The file shows the hearing aids were not provided by the Plan's 
hearing network vendor. Based on this information, we decided that the Plan's rules for coverage of the hearing 
aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids provided on 
June 4, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda (J9271). 
 
You asked the Plan to pre-approve Keytruda. You say that the medication is necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Keytruda. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found the requested use of Keytruda as 
monotherapy is not FDA approved or supported by any of the CMS approved compendia. This reviewer did 
not find any supportive citations in a PubMed search. Therefore the documentation does not support that 
Keytruda is medically reasonable and necessary or safe and effective 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 Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda (J9271).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for creatinine testing (82565) provided on May 27, 2020. 
 
You asked the Plan to pay for creatinine testing. You say that this is supported by the records. The Plan denied 
your request. The Plan says this is not documented. 
 
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 82565 is creatinine; blood. 
 
We find that CPT code 82565 is not supported in the medical record. Specifically, there is no documentation of 
this test being performed or documentation of the results. Based on this information, we decided that Medicare 
rules for coverage of creatinine testing have not been met. Therefore, we decided that the Plan does not have to 
pay for creatinine testing (82565) provided on May 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided by an out-of-network provider. 
 
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the 
denied charges. The Plan denied your request. The Plan says you do not have out-of-network benefits. 
 
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. 
 
This provider is out-of-network. The health plan contract says services are covered only when you are treated 
by a contracted dental provider. 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 dental services provided 
by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan of the abdomen and pelvis 
(74176) performed on June 5, 2020. 
 
You asked the Plan to waive the copayment for a CT scan of the abdomen and pelvis. You say that you are 
unable to pay this bill. The Plan denied your request. The Plan says the correct copayment was 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 a $200 
copayment for CT scans.  
 
You have been asked to pay a $200 copayment for a CT scan of the abdomen and pelvis. A CT scan of the 
abdomen and pelvis falls within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 CT scan of the abdomen and pelvis (74176) 
performed on June 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the limited oral evaluation (D0140) and 
panoramic x-ray (D0330) provided on April 20, 2020. 
 
You asked the Plan to reimburse you for the dental services. You say that you were in a bicycle accident. You 
say that you had to go see an oral surgeon. You say that the services were necessary. You also say that you 
were told to go see a particular provider. The Plan denied your request. The Plan says that the provider in this 
case is not a network provider. The Plan also says that services that you receive out of network are not covered.  
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to reimburse you for involve the care, treatment, filling, removal or 
replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not 
covered or paid for by Medicare. Therefore, we decided that the Plan does not have to reimburse you for the 
limited oral evaluation (D0140) and panoramic x-ray (D0330) provided on April 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transportation of portable x-ray equipment with CPT 
code R0075 provided on August 12, 2020. 
 
You asked the Plan to pay for CPT code R0075. 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. 
 
We looked at the file and Medicare rules. The review shows that the medical records provided represent 
professional charges; however, procedure code R0075 was provided in a facility with a place of service 31. 
Procedure code R0075 has a PC/TC Modifier Status of 3, which specifies a Technical Component only code. 
Therefore, we decided that the Plan does not have to pay for the transportation of portable x-ray equipment 
with CPT code R0075 provided on August 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics. 
 
You asked the Plan to pay for foot orthotics. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on October 9, 2019. You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says insufficient medical records were submitted to show this service was required out of network.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the 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 forthe medical services provided on October 9, 2019 by an out of network (OON) provider