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

 
We decided that the Plan does not have to waive the coinsurance for an Erythropoietin injection (Q5105) 
provided April 6, 2020. 
 
You asked the Plan to waive the coinsurance for the injection. You say that the coinsurance should be waived. 
The Plan denied your request. The Plan says the correct cost-sharing 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 15% 
coinsurance for Part B Drugs.  
 
You have been asked to pay a 15% coinsurance for the injection. The injection falls within the Part B Drugs 
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 coinsurance for an Erythropoietin injection 
(Q5105) provided April 6, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for a high frequency chest wall oscillation system (E0483) provided on 
December 4, 2019. 
 
You asked the Plan to pay for the high frequency chest wall oscillation system. You say that you would like 
reconsideration because these supplies were authorized and the physician order is appropriate. The Plan denied 
your request. The Plan says that the physician order does not include the length of time the Durable Medical 
Equipment is needed with start/stop dates. 
 
The Plan must follow Medicare rules. Medicare rules say that for all Durable Medical Equipment, Prosthetic, 
and Orthotic Supplies (DMEPOS) must have an order from the treating physician before giving any DMEPOS 
item to an enrollee. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the high frequency chest wall oscillation system have been met. Specifically, the physician order 
includes the beneficiary name, description of the item and physician signature. Per Medicare, the duration of 
need is not required documentation. Therefore, we decided that the Plan has to pay for a high frequency chest 
wall oscillation system (E0483) provided on December 4, 2019.  
 
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 infection agent detection services provided to the enrollee on 
May 14, 2020. 
 
You asked the Plan to pay for the services. You say that the lab report results show that all the work has been 
performed. The Plan denied your request. The Plan says Medicare says screening services with no relation to a 
medical diagnosis of disease for the health of the patient are not a benefit. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there were no clinical notes provided to show an indication for this testing, however, based on other tests 
ordered at the same time, (urinalysis, urine microscopy) it is possible this patient had signs or symptoms or 
UTI. However, regardless, PCR testing is not standard of care as there isn't sufficient evidence to suggest it is 
better than current standards of using signs and symptoms, urinalysis, urine microscopy, and urine culture to 
help make clinical decisions. Therefore, clinical documentation to suggest UTI and without evidence to support 
this test, this request for infectious agent detection by nucleic acid testing will be considered not medically 
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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for infection agent detection services provided to the enrollee on May 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist services and coinsurance for 
medical supplies provided by a participating provider on May 4, 2020 to May 25, 2020. 
 
You asked the Plan to waive the copayment for specialist services and coinsurance for medical supplies. You 
say that you were told this was covered 100%. The Plan denied your request. The Plan says the correct 
copayment and coinsurance 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 a $45 
copayment for physician/practitioner services/specialist and a 20% coinsurance for durable medical 
equipment/in-network.  
 
You have been asked to pay a $45 copayment for specialist services and a 20% coinsurance of the allowed 
amount for medical supplies. The total allowed amount is $52.23. The total amount you are being asked to pay 
for medical supplies is $10.45 ($52.23 x 20% = $10.45). The total amount you are being asked to pay is $55.45 
($45 + $10.45 = $55.45). Specialist services falls within the physician/practitioner services/specialist benefit 
category. Medical supplies fall within the durable medical equipment/in-network 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 and coinsurance for specialist services and medical supplies provided by 
a participating provider on May 4, 2020 to May 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance provided on May 12, 2020. 
 
You asked the Plan to pay for periodontal maintenance. You say that this was your routine, twice a year teeth 
cleaning. You say that the same service was submitted in 2019 and was paid. The Plan denied your request. 
The Plan says the service is not a covered benefit. 
 
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 
periodontal maintenance provided on May 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on July 2, 2020. 
 
You asked the Plan to pay for the domiciliary or rest home visit. 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 a domiciliary or rest home visit provided on July 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of intact mammary implant services coded 
19328 provided on November 12, 2019. 
 
You asked the Plan to pay for the removal of intact mammary implant services. 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 
supported by the documentation. 
 
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 19328 is removal of intact mammary implant. 
 
We find that CPT code 19328 is not supported in the medical record. Specifically, the operative report did not 
include documentation of a removal of an intact mammary implant, as a separate procedure. Based on this 
information, we decided that Medicare rules for coverage of the removal of intact mammary implant services 
have not been met. Therefore, we decided that the Plan does not have to pay for the removal of intact 
mammary implant services coded 19328 provided on November 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the clonidine hydrochloride injection services coded J0735, 
the morphine sulfate injection services coded J2270, the fentanyl citrate injection services coded J3010, and the 
unclassified drug injection services coded J3490 provided on March 19, 2020. 
 
You asked the Plan to pay for the clonidine hydrochloride injection services, the morphine sulfate injection 
services, the fentanyl citrate injection services, and the unclassified drug injection services. 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 supported by the documentation. 
 
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 codes J0735, J2270, J3010 and J3490 are not supported in the medical record. Specifically, 
the submitted documentation indicates that morphine, bupivacaine, fentanyl and clonidine were 
mixed/compounded. A more appropriate code should have been billed for these services. Based on this 
information, we decided that Medicare rules for coverage of the clonidine hydrochloride injection services, the 
morphine sulfate injection services, the fentanyl citrate injection services, and the unclassified drug injection 
services have not been met. Therefore, we decided that the Plan does not have to pay for the clonidine 
hydrochloride injection services coded J0735, the morphine sulfate injection services coded J2270, the fentanyl 
citrate injection services coded J3010, and the unclassified drug injection services coded J3490 provided on 
March 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair accessories (E2377, E2313, E2311). 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says although there are three approved power options on this wheelchair (tilt, recline 
and elevating leg rests), there is not a medical need to control these power options through the joystick. 
 
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 pre-approve the accessories. Our reviewer says that 
the requested accessories are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation does not support the need for a joystick. Your mobility needs can be met 
with the approved power chair with approved options. 
 
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 accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve power wheelchair accessories (E2377, E2313, E2311).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the radiation therapy services provided on 
December 30, 2019 and January 2, 2019. 
 
You asked the Plan to waive the copayments for the radiation therapy services. The Plan denied your request. 
The Plan says that this processed correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $60 
copayment per visit for nuclear medicine and radiation therapy, including but not limited to cancer treatment.  
 
You have been asked to pay a $120 copayment for the radiation therapy services. The radiation therapy 
services fall within the visit for nuclear medicine and radiation therapy, including but not limited to cancer 
treatment 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 the radiation therapy 
services provided on December 30, 2019 and January 2, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (HCPCS A0427) provided to the 
enrollee. 
 
You asked the Plan to pay for the services. You say that you did not transport the enrollee, and that the services 
were provided in an attempt to revive the enrollee. The Plan denied your request. The Plan says A0427 is not 
the service code that CMS instructs be used. 
 
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 October 13, 2019. 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 ambulance services (HCPCS A0427) provided to 
the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on March 27, 2020. 
 
You asked the Plan to pay for the physician's services. 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 
physician's services. 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 physician's services provided on March 27, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on May 6, 2020. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 Guardant360 testing is not supported in the medical record. Specifically, this service should be 
billed with code 81479. In addition, the appropriate DEX Z code identifier should be entered adjacent to the 
code in the comment/narrative field. Based on this information, we decided that Medicare rules for coverage of 
the Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
Guardant360 testing provided on May 6, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the immunoassay services provided. 
 
You asked the Plan to pay for the immunoassay services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services rendered 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 immunoassay testing services at issue in this appeal were requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pay for the immunoassay services provided.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on May 1, 2020. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 Guardant360 testing is not supported in the medical record. Specifically, this service should be 
coded with code 81479. In addition, the appropriate DEX Z Code identifier should be entered adjacent to the 
code in the comment/narrative field. Based on this information, we decided that Medicare rules for coverage of 
the Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
Guardant360 testing provided on May 1, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on January 16, 2020. 
 
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
member?s terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for ambulance services provided on January 16, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on June 4, 2019. 
 
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 claim was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 11 for a 
laboratory setting; however, the file shows that the specimen was obtained in an outpatient rehabilitation 
setting and should have been billed with POS code 57. Therefore, we decided that the Plan does not have to 
pay for the drug testing rendered on June 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation provided on May 
15, 2020. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you were instructed by 
your general dentist to see a specialist who could deal with your situation. You also say that you feel these 
services should have been covered. The Plan denied your request. The Plan says your oral evaluations benefit 
has been exhausted. 
 
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, oral evaluations are limited to 1 every 
6 months. The record shows that you received an oral evaluation on April 30, 2020 and your oral evaluations 
benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused 
limited oral evaluation provided on May 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endovenous ablation therapy of incompetent vein (36475) 
provided.
 
You asked the Plan to pay for the therapy. You say that you would like reconsideration because the services 
rendered were medically necessary. The Plan denied your request. The Plan says a 0, 10 or 90-day post-
operative procedure was not found in the member?s claims history during its applicable post-operative period. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that CPT code 36475 is not supported in the record. Specifically, the record does not show an 
unrelated post-operative procedure. The use of modifier -79 is inappropriate in this case. Based on this 
information, we decided that Medicare rules for coverage of the therapy have not been met. Therefore, we 
decided that the Plan does not have to pay for endovenous ablation therapy of incompetent vein (36475) 
provided.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an X-Ray examination provided on February 7, 2020. 
 
You asked the Plan to pay for X-Ray exam. You say that the Plan is responsible for this charge. The Plan 
denied your request. The Plan says the denial of payment for this service is correct, because this provider is not 
eligible for Medicare payment. 
 
The Plan must follow Medicare rules. Medicare rules say that payment may not be made for items and services 
furnished by a provider or agency of the Federal government, including a VA medical center.  
 
We looked at the file and Medicare rules. This provider is a provider of the United States Department of 
Veterans Affairs, an agency of the Federal government, and is therefore not eligible for payment by Medicare. 
Based on this information, we decided that Medicare rules for coverage of X-Ray exam have not been met. 
Therefore, we decided that the Plan does not have to pay for an X-Ray examination provided on February 7, 
2020.