Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy services provided from December 3, 
2019, to December 10, 2019. 
 
You asked the Plan to pay for home infusion therapy services (S9502). You say that the Plan should pay this 
claim. The Plan denied your request. The Plan says this procedure code is not valid for Medicare purposes. 
 
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 S9502 is Home infusion therapy, antibiotic, antiviral, or 
antifungal therapy; once every 8 hours, administrative services. 
 
We find that CPT code S9502 is not a valid code for Medicare purposes. S codes are unique temporary codes 
established by BCBSA and HIAA for private payor use. They are not valid nor payable by Medicare. Medicare 
uses another code for reporting of, and payment for, these services. Based on this information, we decided that 
Medicare rules for coverage of home infusion therapy management have not been met. Therefore, we decided 
that the Plan does not have to pay for home infusion therapy services provided from December 3, 2019, to 
December 10, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core build up (D2950). 
 
You asked the Plan to pre-approve the core build up. You say that the services are necessary. The Plan denied 
your request. The Plan says core build up is not a covered service. 
 
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 core 
build up (D2950).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the humidifier provided on August 2, 
2020. 
 
You asked the Plan to waive the coinsurance for the humidifier. You say that you cannot afford the increase in 
cost every month. The Plan denied your request. The Plan says the coinsurance 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 durable medical equipment and related supplies.  
 
You have been asked to pay $3.53, which is 20% of the allowed amount for the humidifier. The allowed 
amount is $17.67 (20% x $17.67 = $3.53). The humidifier falls within the "Durable medical equipment (DME) 
and related 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 coinsurance for the humidifier 
provided on August 2, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve routine transportation. You say that riding in a van with other passengers 
causes a risk of contracting COVID-19 and could trigger your anxiety. The Plan denied your request. The Plan 
says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan 
and you can receive routine transportation from the Plan's in-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 
the medical services to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing (80307, G0480) performed. 
 
You asked the Plan to pay for drug testing. You say that these services should be paid for by the Plan. The Plan 
denied your request. The Plan says rules for payment have not been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, the medical records submitted from the ordering 
physician did not corroborate the billed services. There was also not a valid order within the record. Therefore, 
we decided that the Plan does not have to pay for drug testing (80307, G0480) performed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic casts (D0470) provided on June 24, 2020. 
 
You asked the Plan to pay for the dental service. You say that you are on a fixed income. You also say that now 
you have to pay monthly payments for these services. The Plan denied your request. The Plan says diagnostic 
cast is not listed as a covered service. 
 
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 
diagnostic casts (D0470) provided on June 24, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory services (36415, 84153, 
84520, 85025) provided August 14, 2020. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that the lab service was not 
appropriate. The Plan denied your request. The Plan says the copayment applied correctly in this case. 
 
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 $10 
copayment for diagnostic lab services and diagnostic procedures and tests.  
 
You have been asked to pay a $10 copayment for the laboratory services. The services provided fall within the 
diagnostic lab services and diagnostic procedures and tests 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 laboratory services (36415, 84153, 84520, 85025) provided August 14, 2020.  
 
Maximus Federal Services read your letter and knows that you may have a quality of care concern. We cannot address quality of care issues. We are forwarding your quality of care concern to the 
appropriate Quality Improvement Organization for further review.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on May 7, 2019. 
 
You asked the Plan to pay for the ambulance services. You say that the claim was timely submitted to other 
insurance. The Plan denied your request. The Plan says the claim was untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the ambulance services was not filed until May 28, 2020. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the ambulance services provided on May 7, 2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. 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 must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the beneficiary does not require skilled 
nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of 
service criteria for an inpatient basis in a skilled nursing facility setting. 
 
 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high dose flu vaccine (Fluzone). 
 
You asked the Plan to pre-approve a high dose flu vaccine. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
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 a high dose flu vaccine. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found you received an influenza vaccationation in September.  The documentation does not 
include provider documentation outlining medical necessity for a second vaccination or the high dose 
quadrivalent vaccination. Without the support of the documentation, the request is determined not medically 
necessary. Therefore, you do not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a high dose flu vaccine have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a high dose flu vaccine (Fluzone).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to apply in-network cost sharing for the laboratory services provided by an out of 
network laboratory on June 1, 2020. 
 
You asked the Plan to apply in-network cost sharing for the lab services. You say that the enrollee was unable 
to have visitors or leave her assisted living facility and requires lab testing due to unusual behavior requiring a 
check to see if she had an infection. This testing needed to be done by the lab contracted with the facility as she 
could not be brought to a network lab. The Plan denied your request. The Plan says that this was correctly 
applied to the deductible for out of network lab testing. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis, and 
pre-approved care.   
 
The documentation indicates that the enrollee required lab testing urgently to address new symptoms. Due to 
COVID restrictions, she was not able to leave her facility to access a network lab. Since no network facilities 
were accessible during this urgent medical situation, the criteria for in-network coverage are met. Therefore, we 
decided that the Plan has to apply in-network cost sharing for the laboratory services provided by an out of 
network laboratory on June 1, 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: Unfavorable

We decided that the Plan does not have to pay for the domiciliary visit (99326) and debridement of nails 
(11721) provided on April 22, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for domiciliary visit and debridement of nails. You say that the services were 
rendered by a provider the enrollee was referred to. The Plan denied your request. The Plan says prior 
authorization must be obtained for non-emergent services rendered by an out-of-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the domiciliary visit (99326) and debridement of 
nails (11721) provided on April 22, 2019 by an out of network (OON) provider.  
 
Your complaint about when you were contacted for the charge is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for infectious agent detection testing provided on March 18, 
2020. 
 
You asked the Plan to pay for lab test. You say that you are appealing based on medical necessity. The Plan 
denied your request. The Plan says the denial of payment for this service is correct, because this testing is not 
covered under the circumstances. 
 
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 lab test. Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there was no clinical rationale provided for this testing. Use of this test is restricted to when more limited 
panels would not be medically appropriate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lab test have not been met. Therefore, we decided that the Plan does not have to 
pay for infectious agent detection testing provided on March 18, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on March 9, 2020. 
 
You asked the Plan to waive the copayment for the office visit. You say that you didn't do anything extra. You 
say that you don't agree with the charge. The Plan denied your request. The Plan says the claim reprocessed to 
only apply one $35 copayment. 
 
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 $35 
copayment per individual or group visit for outpatient mental health care. 
 
You have been asked to pay a $35 copayment for the office visit. The office visit 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 copayment for the office visit 
provided on March 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950) for teeth # 14, 28, 29 and 30. 
 
You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied 
your request. The Plan says core build up is not listed as a covered service. The Plan also says any services not 
listed 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 pre-approve core 
build up (D2950) for teeth # 14, 28, 29 and 30.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe screening laboratory tests provided on April 22, 2020.You asked the Plan to pay forthe allergy, antibody, celiac profiles. You say that the tests were necessary.The Plan denied your request. The Plan says these tests are considered experimental and investigational.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 test at issue in this appeal, the allergy, antibody, celiac profiles, was 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 forthe screening laboratory tests provided on April 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction (D7140) provided on May 15, 2020. 
 
You asked the Plan to pay for the dental service. You say that you were not able to find an in-network dentist 
that would see you due to COVID-19. You say that you were advised by a plan representative that you should 
go to your regular dentist office as they were in network. You say that a dentist from your regular dentist office 
set you up to see this dentist to get your tooth pulled. The Plan denied your request. The Plan says the dental 
provider in this case is not a participating dental provider. The Plan says the referring provider in this case is 
not a participating dental 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, the extraction you received is not 
among those covered under this benefit when received out of network. Therefore, we decided that the Plan does 
not have to pay for the extraction (D7140) provided on May 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the enrollee requires the device. 
The Plan denied your request. The Plan says the documentation failed to prove that sufficient evidence of four-
week trial of conservative therapy. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0651 is covered for the treatment of 
lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. A four-week 
trial of conservative therapy demonstrating failed response to treatment is required. 
 
 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular home usage of conservative therapy documented including compression garments, 
exercise and elevation. Therefore, we decided that the Plan does not have to pay for a pneumatic compression 
device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic care (98941 and 97012) provided on August 
9, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for chiropractic care. You say that you were referred to this provider. The Plan 
denied your request. The Plan says prior authorization must be obtained for non-emergent services rendered by 
an out-of-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the chiropractic care (98941 and 97012) provided 
on August 9, 2019 by an out of network (OON) provider.