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

 
We decided that the Plan does not have to pay for the laboratory testing provided on December 12, 2019. 
 
You asked the Plan to pay for the laboratory testing. 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 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 test at issue in this appeal, the laboratory testing, 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 
for the laboratory testing provided on December 12, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Hyaluronan injection. 
 
You asked the Plan to pre-approve the requested injection. The Plan denied your request. The Plan says the 
enrollee has not had an inadequate response to Synvisc and Euflexxa. 
 
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 the requested injection. Our physician 
reviewer found the request for a Hyaluronan injection for the treatment of osteoarthritis in the right knee. The 
Plan requires a trial of Synvisc and Euflexxa before they will approve the requested drug. The enrollee has not 
trialed Synvisc or Euflexxa. The documentation does not outline contraindications or reasons these medications 
were not considered. Without the support of the documentation, a Hyaluronan injections is 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 the requested injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Hyaluronan injection.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Assembly and operation of pump with oxygenator or heat 
exchanger (99190) provided April 22, 2020. 
 
You asked the Plan to pay for the assembly and operation of the oxygenator. You say that the services were 
medically necessary. The Plan denied your request. The Plan says the service was performed in a hospital and 
cannot be paid separately. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99190 is not supported in the medical record. Specifically, the services were rendered 
in a facility during inpatient hospitalization, and payment for this service would be included in the part-A DRG 
payment to the facility. This service is not eligible for separate payment. Based on this information, we decided 
that Medicare rules for coverage of the assembly and operation of the oxygenator have not been met. 
Therefore, we decided that the Plan does not have to pay for the Assembly and operation of pump with 
oxygenator or heat exchanger (99190) provided April 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care evaluation and management service provided on 
March 23, 2019. 
 
You asked the Plan to pay for critical care service. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the denial of payment for this service is correct, because the 
documentation does not support that a critical care visit of 30 to 74 minutes was performed on the billed date of 
service. 
 
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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30 to 74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the documentation does not 
support that this critical care service was 30 to 74 minutes in duration. Based on this information, we decided 
that Medicare rules for coverage of critical care service have not been met. Therefore, we decided that the Plan 
does not have to pay for critical care evaluation and management service provided on March 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additions to a prosthetic limb (L5631 and L5790) for the 
enrollee. 
 
You asked the Plan to pre-approve the additions. You say that these are important pieces of the prosthetic limb. 
The Plan denied your request. The Plan says these codes cannot be approved. 
 
The Plan must follow Medicare rules. The rules say that L5631 and L5790 will be denied as not reasonable or 
necessary when provided with a prosthesis. 
 
The requested codes are statutorily not covered. Based on this information, we decided that Medicare rules for 
coverage of the additions have not been met. Therefore, we decided that the Plan does not have to pre-approve 
additions to a prosthetic limb (L5631 and L5790) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the X-ray services (71046, Q0092, R0070) provided on July 
6, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the X-ray services. You say that the services provided were medically necessary. 
The Plan denied your request. The Plan says prior authorization was not obtained by the facility or the 
provider; therefore, payment has been correctly denied. 
 
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 X-ray services (71046, Q0092, R0070) 
provided on July 6, 2020, by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a nail (11721) and wound (97597) 
debridement performed on June 17, 2020. 
 
You asked the Plan to waive the copayment for a nail and wound debridement. You say that you were informed 
you would not have to pay any deductible for medical treatment. 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 $50 
copayment for surgery services at a specialist's office.  
 
You have been asked to pay a $50 copayment for a nail and wound debridement. A nail and wound 
debridement falls within the "Physician/Practitioner services, including doctor's office visits" 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 nail (11721) and wound (97597) debridement performed 
on June 17, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transportation services you received from March 8, 2020, 
to March 22, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says you did not call to 
arrange transportation. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan?s coverage rules apply in this 
case. The Plan covers routine transportation when arrangements are made at least 3 weekdays prior to 
appointment. 
 
We looked at your request, the records in the case file, and the rules. The records do not show that you made 
arrangements with the Plan for these transportation services at least 3 weekdays prior to the transportation. 
Based on this information, we decided that the Plan?s rules for coverage of routine transportation have not been 
met. Therefore, we decided that the Plan does not have to pay for the transportation services you received from 
March 8, 2020, to March 22, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on June 25, 2019. 
 
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 an internal review of codes 81225, 81226, 81227, 81401, 81401, 81479, 81479 and 
81479 showed that these codes represent part of an expanded pharmacogenomic panel. The Centers for 
Medicare & Medicaid Services (CMS) National Correct Coding Initiative Coding Policy Manual for Medicare 
Services states if one laboratory procedure evaluates multiple genes utilizing a next generation sequencing 
procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular 
multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis CPT code. 
If no CPT code accurately describes the procedure performed, the laboratory shall report CPT code 81479 
(unlisted molecular pathology procedure) with one unit of service. The laboratory shall not report multiple 
individual CPT codes describing the component test results. If a single procedure is performed, only one 
HCPCS/CPT code with one unit of service may be reported for the procedure. Based on these Medicare 
guidelines, this claim was billed incorrectly, therefore, the claim remains denied.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT codes. In this case, the claim submitted cannot be paid 
as billed due to an error with the codes reported. Medicare billing criteria were not met. Based on this 
information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we 
decided that the Plan does not have to pay for lab services provided to the enrollee on June 25, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve the additional transportation. You say that you would like reconsideration 
because additional transportation is necessary due to the member's condition. The Plan denied your request. 
The Plan says this benefit will be exhausted after 24 trips. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan?s coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the member will have exhausted the Plan maximum benefit for coverage of routine transportation after 24 
trips. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested physician's services.  
 
You asked the Plan to pre-approve the physician's services. You say that that you want to go to a rheumatology 
practice run by women, as you would feel more comfortable with this practice. The Plan denied your request. 
The Plan says in most cases, care you receive from an out-of-network provider will not be covered, with the 
following three exceptions: emergency care or urgently needed services, Medicare-covered medical care that 
the providers in our network cannot provide, and dialysis services at a Medicare certified dialysis facility when 
you are temporarily outside the plan's service area. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the 
requested physician's services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213). 
 
You asked the Plan to pre-approve the maxillary partial denture. You say that the denture is necessary for your 
health. The Plan denied your request. The Plan says this service is not covered under your plan. 
 
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 a 
maxillary partial denture (D5213).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Cardiac Computed Tomography (CT) with calcium scoring 
(75571) provided June 1, 2020. 
 
You asked the Plan to pay for the CT scan. You say that the service was medically necessary. The Plan denied 
your request. The Plan says documentation does not support the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 75571 is not supported in the medical record. Specifically, the service at issue is non-
covered for the diagnosis code listed. Based on this information, we decided that Medicare rules for coverage 
of the CT scan have not been met. Therefore, we decided that the Plan does not have to pay for Cardiac 
Computed Tomography (CT) with calcium scoring (75571) provided June 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office outpatient visit (99213) provided on March 17, 
2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for office outpatient visit. You say that telemedicine does not require prior 
authorization. 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 office outpatient visit (99213) provided on 
March 17, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to provide ophthalmology services with a previous treating physician. 
 
You asked the Plan to provide out of network ophthalmology services. You say that you want to be treated by 
your previous doctor who you have been with for many years. The Plan denied your request. The Plan says the 
services are available in network and your condition is not an emergency. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees? needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Services are available in network. Based on 
this information, we decided that Medicare rules for coverage of out of network ophthalmology services have 
not been met. Therefore, we decided that the Plan does not have to provide ophthalmology services with a 
previous treating physician.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endodontic procedure (D3999). 
 
You asked the Plan to pre-approve the endodontic procedure. The Plan denied your request. The Plan says this 
service is not covered under your benefit plan. 
 
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 an 
endodontic procedure (D3999).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Trelegy Ellipta for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Trelegy Ellipta for the 
enrollee.  
 
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on October 1, 2019. 
 
You asked the Plan to pay for the lab services. 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 requested CPT codes are not supported in the medical record. Specifically, the records do not 
show that the testing was performed on blood sampling. The records show that a urine specimen was collected. 
The billed services cannot be verified. Based on this information, we decided that Medicare rules for coverage 
of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab 
services provided on October 1, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an IRF stay on May 16 to May 19, 2020. 
 
You asked the Plan to waive the copayment for an IRF stay. You say that you were told by your caseworker 
that you would have no out-of-pocket cost. 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 $300 
copayment for each day for days 1-5 of Medicare-covered inpatient hospital stays.  
 
You have been asked to pay $600, or a $300 copayment for 2 days of an IRF stay. An IRF stay falls within the 
"Inpatient hospital 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 an IRF stay 
on May 16 to May 19, 2020.  
 
Your complaint about receiving erroneous or ambiguous information from your caseworker 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core buildup, including any pins when required 
(D2950). 
 
You asked the Plan to pre-approve the core buildup. You say that the approved code D2740 cannot be 
performed without the D2950. You also say that this is one procedure that is done in steps, and has been coded 
separately. The Plan denied your request. The Plan says this service 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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
core buildup, including any pins when required (D2950).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the established patient home visit (99348) provided on April 
8, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the established patient home visit. You say that no authorization is needed for 
payment of services rendered under telemedicine. The Plan denied your request. The Plan says prior 
authorization was not obtained by the facility or the provider; therefore, payment has been correctly denied. 
 
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 established patient home visit (99348) 
provided on April 8, 2020, by an out of network (OON) provider.