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

 
We decided that the Plan does not have to waive the copayment for lab tests you received on August 4, 2020. 
 
You asked the Plan to waive the copayment for the lab tests. You say that you shouldn't have to pay this 
copayment because these labs were ordered as a part of your wellness exam. The Plan denied your request. The 
Plan says you were charged this copayment 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 $20 
copayment for Tier 2 laboratory services.  
 
You have been asked to pay a $20 copayment for the lab tests. The records show that in order to have a $0 
copayment for lab services, you must have a Tier 1 PCP and you must receive the labs at a Tier 1 facility.  
Records from the Plan show that neither your PCP nor the facility that performed these labs is a Tier 1 
provider.  In addition, your Evidence of Coverage clearly states that lab services performed or ordered during 
your wellness exam are subject to cost sharing. 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 lab tests you 
received on August 4, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the TDAP vaccine received on July 21, 2020. 
 
You asked the Plan to pay for the TDAP vaccine. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says this service is not a covered benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the TDAP vaccine. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the TDAP vaccine. 
Therefore, we decided that the Plan does not have to pay for the TDAP vaccine received on July 21, 2020.  
 
Benefits for the TDAP vaccine 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 laboratory services provided on March 30, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services provided 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 laboratory testing at issue in this appeal 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 services provided on March 30, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve lynch syndrome genetic testing. 
 
You asked the Plan to pre-approve lynch syndrome genetic testing. You say that the requested lynch syndrome 
genetic testing is medically necessary. The Plan denied your request. The Plan says that the enrollee does not 
meet criteria for the requested lynch syndrome genetic testing. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 lynch syndrome genetic testing. Our 
reviewer says that the requested lynch syndrome genetic testing is medically necessary.  Our physician 
reviewer found this enrollee has both a personal history of colon cancer and a known Lynch syndrome variant 
in the MLH1 gene in her son. Her family history is strongly suggestive of an inherited gene and her son is 
known to carry MLH1. She should be tested for MLH1 and if negative, then panel testing. The service is 
reasonable and 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 lynch syndrome genetic testing have been met. Therefore, we decided that the 
Plan has to pre-approve lynch syndrome genetic testing.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the nuclear medicine study of vessels of 
heart (78452) and regadenoson injection (J2785) provided on June 8, 2020. 
 
You asked the Plan to waive the cost share for the nuclear medicine study of vessels of heart and regadenoson 
injection. You say that you do not understand why you are being billed for two services. The Plan denied your 
request. The Plan says the cost share 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 $125 
copayment for Medicare covered diagnostic radiology services and a 20% coinsurance for Medicare Part B 
drugs. 
 
You have been asked to pay a total cost share of $172.50 ($125 + $47.5) for Medicare Part B drugs ($237.48 
allowed amount x 20% = $47.5) and the nuclear medicine study of vessels of heart and regadenoson injection 
($125 copayment). The services provided fall within the Medicare covered diagnostic radiology services and 
Medicare 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 cost share for the nuclear medicine study of vessels of heart 
(78452) and regadenoson injection (J2785) provided on June 8, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for to pay for drug testing provided to the enrollee on January 
13, 2020 and billed under code G0481. 
 
You asked the Plan to pay for drug testing provided to the enrollee. You say that this claim should be paid. The 
Plan denied your request. The Plan says the place of service code on the CMS-1500 form line 24B must reflect 
the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory 
specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim 
history indicates that the specimen was obtained in an office setting POS 11.  Also, the laboratory results 
submitted indicate the specimen was collected on January 13, 2020 and received by the lab on January 14, 
2020; therefore, the billed code cannot be verified.  It is noted multiple attempts were made to obtain additional 
information from the provider.  
 
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, code G0481 cannot be paid due to 
an issue with the POS code reported. Medicare billing criteria are not met.  Therefore, we decided that the Plan 
does not have to pay for to pay for drug testing provided to the enrollee on January 13, 2020 and billed under 
code G0481.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab testing services provided on May 13, 2019. 
 
You asked the Plan to pay for the lab services. You say that you should not be financially responsible for 
preventive services. The Plan denied your request. The Plan says that the services are not payable by Medicare. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the lab services by a contract provider. The file does not show that the Plan provided 
notice that the lab services would not be covered. Under Medicare rules, this means the lab services is 
considered approved by the Plan. Therefore, we decided that the Plan has to pay for the lab testing services 
provided on May 13, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services coded 99291 provided on May 13, 
2020. 
 
You asked the Plan to pay for the critical care 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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the documentation submitted 
did not support a critical care visit of 30-74 minutes was performed on the billed date of service. The 
documentation does not clearly indicate a critical care evaluation and management note supporting 30-74 
minutes of critical care. Based on this information, we decided that Medicare rules for coverage of the critical 
care services have not been met. Therefore, we decided that the Plan does not have to pay for the critical care 
services coded 99291 provided on May 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on January 30, 2020 by a non-
network provider. 
 
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 services were rendered by a non-network provider without 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 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 medical services provided on January 30, 2020 
by a non-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab services you received at an outpatient 
hospital facility on August 6, 2020. 
 
You asked the Plan to waive the copayment for the lab services. You say that the doctor's office staff didn't tell 
you that if you had bloodwork at the hospital there would be a copayment.  You said that if you had known, 
you would have gone to an independent lab so that you wouldn't have a copayment. The Plan denied your 
request. The Plan says you were charged this copayment correctly.  The Plan says that this copayment is clearly 
disclosed to you in your Evidence of Coverage. 
 
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 $30 
copayment for lab services performed in an outpatient hospital facility.  
 
You have been asked to pay a $30 copayment for the lab services. 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 lab services you received at an outpatient hospital facility on August 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower partial denture (D5214). 
 
You asked the Plan to pre-approve the dental item. You say that the partial denture is medically necessary. The 
Plan denied your request. The Plan says partial denture is covered once every 5 plan years. The Plan also says 
that the frequency limit 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, the frequency limit of 1 partial denture 
every 5 plan years has been exhausted. The record shows that the Plan paid for a lower partial denture that the 
enrollee received on August 6, 2018, less than 5 years ago. Therefore, we decided that the Plan does not have 
to pre-approve a lower partial denture (D5214).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography (CT) scan code 71250-26, provided to 
the enrollee on July 28, 2020. 
 
You asked the Plan to pay for this imaging. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee had a CT scan of the chest on July 28, 2020.  The submitted documentation 
supports 1 (one) unit of 71250-26, which was previously approved and paid. There is no additional 
documentation supporting an additional study which was billed and remains denied.  The reports submitted are 
duplicates of each other.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case the claim submitted lacks a modifier that 
would show this was a separate and distinct service from a claim previously paid. Medicare rules for coverage 
of this claim have not been met. Therefore, we decided that the Plan does not have to pay for computed 
tomography (CT) scan code 71250-26, provided to the enrollee on July 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the outpatient office visit (99205) to be provided by an
out-of-network (OON) provider.
You asked the Plan to pre-approve the office visit. You say that you don't want to wait around if there's
something wrong. It is starting to hurt when you swallow. The Plan denied your request. The Plan says
enrollee's must receive their medical services from an in-network provider. Non-emergent services with noncontracted
providers require prior authorization before services being rendered. The plan has confirmed and
approved services to be provided in-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 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 outpatient office visit (99205) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a facet joint block. 
 
You asked the Plan to pre-approve a facet joint block. You say that the requested facet joint block is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet LCD criteria for the 
requested facet joint block. 
 
 
 
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 facet joint block. Our reviewer says 
that the enrollee does not meet LCD criteria for the requested facet joint block. Our physician reviewer found 
the enrollee is with a history of lumbar spondylosis without myelopathy. She has been treated with medical 
therapy and physical therapy. The documentation indicates that in an office visit note dated 10/27/2020 the 
enrollee stated that she received 50% relief with the first medial branch block (MBB). The provider has 
requested a second MBB. Per the coverage criteria: Diagnostic Facet Joint Injections: Dual MBBs (a series of 
two MBBs) are necessary to diagnose facet pain due to the unacceptably high false positive rate of single MBB 
injections. A second confirmatory MBB is allowed if documentation indicates the first MBB produced > 80% 
relief of primary (index) pain and duration of relief is consistent with the agent employed. Intraarticular facet 
block will not be reimbursed as a diagnostic test unless medial branch blocks cannot be performed due to 
specific documented anatomic restrictions. 
 
In this case the first MBB provided only 50% pain relief. The review has determined that the enrollee does not 
have a covered indication per the LCD for the requested facet joint block. 
 
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 facet joint block have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a facet joint block.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve OPDIVO for the enrollee. 
 
You asked the Plan to pre-approve OPDIVO. You say that this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says that that the medical records do not show that the member has tried 
previous medications or that the members condition is worsening. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 OPDIVO. Our reviewer says that 
OPDIVO is medically reasonable and necessary for the enrollee in this case. The use of OPDIVO is supported 
by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. 
The patient is not a good candidate for other first line therapies given esophageal varices. Documentation 
supports that OPDIVO is safe and effective and otherwise reasonable and necessary for this enrollee. Our 
physician reviewer found that the enrollee's condition meets Medicare criteria for coverage of OPDIVO. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of OPDIVO have been met. Therefore, we decided that the Plan has to pre-
approve OPDIVO for the enrollee.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for discarded Golimumab from the infusion provided on 
August 14, 2020. 
 
You asked the Plan to waive the coinsurance for discarded Golimumab (J1602JW). You say that you did not 
receive the discarded drug so you should not have to pay coinsurance for it. The Plan denied your request. The 
Plan says that you were charged this coinsurance correctly 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay 20% coinsurance for Medicare Part B prescription drugs 
that are injected or infused.  
 
The Plan says you must pay 20% coinsurance for discarded drug for discarded Golimumab (J1602JW). Based 
on the Plan contract, however, you cannot be asked to pay 20% coinsurance for discarded Golimumab 
(J1602JW). You did not receive the wasted medication therefore you are not responsible for the coinsurance on 
the discarded drug. Therefore, we decided that the Plan has to waive the coinsurance for discarded Golimumab 
from the infusion provided on August 14, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Transcutaneous Electrical Nerve Stimulators (TENS) 
device provided on August 12, 2020. 
 
You asked the Plan to pay for the TENS device. You say that you submitted all the forms to be reimbursed. 
The Plan denied your request. The Plan says the coverage criteria was not met. 
 
The Plan must follow Medicare rules. Medicare rules say that the TENS device is only covered under certain 
medical indications.  
 
We looked at the file and Medicare rules. The documentation does not show that you are enrolled in an 
approved clinical study. Based on this information, we decided that Medicare rules for coverage have not been 
met. Therefore, we decided that the Plan does not have to pay for the Transcutaneous Electrical Nerve 
Stimulators (TENS) device provided on August 12, 2020.