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

We decided that the Plan does not have to pay for the lab testing provided on July 6, 2021.
You asked the Plan to pay for the testing services. You say that the test is proven medically necessary. The
Plan denied your request. The Plan says the testing is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the file, and Medicare rules. The rules say that the testing as billed is not likely to impact
therapeutic decision making. Based on this information, we decided that Medicare rules for coverage of the
testing services have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing
provided on July 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an eye exam received on September 16,
2021.
You asked the Plan to waive the copayment for the services. You say that this was a routine eye exam. The
Plan denied your request. The Plan says the copayment was applied appropriately.
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 eye exams.
You have been asked to pay a $20 copayment for the services. The services fall within the eye exams 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 eye exam received on September 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on May 18, 2021.
You asked the Plan to pay for the services provided. You say that your contract does not preclude both services being done on the same date. The Plan denied your request. The Plan says the service was not billed as required by coding regulations.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
The file shows that the enrollee received an office visit for neck and low back pain. During this visit, the enrollee received osteopathic manipulation. The records do not show that the office visit was significant, separate, and unrelated to the osteopathic services. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the office visit provided on May 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services (97016, 97112, G0283), compound
drugs (J3411, J3415, J3490, J7999), and administration (96372) provided on August 5, 2021.
You asked the Plan to pay for physical therapy services, compound drugs, and administration. You say that this
is supported in the records. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that Medicare Part B pays for outpatient physical
therapy services only if they are furnished by, or under the direct supervision of a physical therapist in private
practice; or by, or incident to the service of a nurse practitioner (NP) or physician assistant (PA) only when that
NP/PA may perform physical therapy services under State law. The rules also say that beginning in July 2015,
claims for compounded drugs shall be submitted using a compounded drug, not otherwise classified (NOC)
code.
We looked at the file and Medicare rules. Review of the file and publicly available records, we find that the
physical therapy services at issue in this case were rendered by an NP/PA who is not licensed to provide
physical therapy in the State of Oklahoma. The multiple drug codes reported on this claim refer to a pre-filled
compounded drug/vitamin syringe. The rules require that any compounded drug be billed using the not
otherwise classified code J7999. As this compounded drug was not billed exclusively with J7999, payment
cannot be made. Because the drugs are not paid as billed, the drug administration code, 96372, also cannot be
paid. Based on this information, we decided that Medicare rules for coverage of physical therapy services,
compound drugs, and administration. have not been met. Based on this information, we decided that Medicare
rules for coverage of physical therapy services, compound drugs, and administration have not been met.
Therefore, we decided that the Plan does not have to pay for physical therapy services (97016, 97112, G0283),
compound drugs (J3411, J3415, J3490, J7999), and administration (96372) provided on August 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the GeneSight testing rendered on March 17, 2021.
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 not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that pharmacogenetics testing is covered when
specific criteria are met.
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 these services. Our reviewer says that the
services were not medically necessary. Our physician reviewer found the enrollee has a listed diagnosis of
moderate single-episode major depressive disorder. The clinical documentation in the case file does not support
that the clinician has made an initial personalized decision for the enrollee based on the enrollee's diagnosis, the
enrollee's other medical conditions, other medications the enrollee is taking, professional judgement, clinical
science and basic science pertinent to the drug (e.g. mechanism of action, side effects), the enrollee's past
medical history and when pertinent family history and the enrollee's preferences and values. The clinical record
does not clearly show the use of or intent to prescribe a drug that has known drug-gene interactions that require
a pharmacogenetics test to be ordered to define the safe use of that drug in that enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pay for the GeneSight testing rendered on March 17, 2021.
Local Coverage Determination (LCD) L35000 and Local Coverage Article (LCA) A56199 referenced by the
Plan are not valid for the state of Ohio where the single-source testing is performed and were not used in the
MAXIMUS determination.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient clinic services rendered on April 13, 2021.
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 not billed correctly.
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis
code.
We looked at the file and Medicare rules. The file shows that the claim was not billed with a valid primary
diagnosis code. Based on this information, we decided that Medicare rules for coverage of these services have
not been met. Therefore, we decided that the Plan does not have to pay for the outpatient clinic services
rendered on April 13, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation services
(A0427, A0425) provided on August 28, 2021.
You asked the Plan to waive the copayment for ambulance transport. You say that you did not want the
ambulance transportation, but you were urged by paramedics to go to the hospital. The Plan denied your
request. The Plan says this claim was processed correctly, and your copayment was assessed in accordance
with your contract.
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 $250
copayment for ambulance services.
You have been asked to pay a $250 copayment for the ambulance transportation. 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 ambulance transportation services (A0427, A0425) provided on August 28,
2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered from February 15, 2021
to February 23, 2021.
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 are not covered.
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be
covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The
Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies.
We looked at the file and Medicare and the Plan's rules. The file shows that home infusion therapy services
were rendered. Based on this information, we decided that Medicare and the Plan's rules for coverage of these
services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion
therapy rendered from February 15, 2021 to February 23, 2021.
Benefits for these services 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and
services provided from July 8, 2021, to July 23, 2021.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you feel this claim was
processed incorrectly and you believed the first 20 days of an inpatient stay had a $0 copayment. The Plan
denied your request. The Plan says this claim was processed correctly, and your copayment was assessed in
accordance with your contract. There is a $325 copayment for each of the first six days of an inpatient hospital
stay. There is a $0 copayment for days after the sixth day.
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 $325
copayment for each of the first six days of an inpatient hospital stay. There is a $0 copayment for additional
hospital days.
You have been asked to pay a $1,950 copayment for an inpatient hospital stay which exceeded six days ($325 x
6 = $1,950). 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 inpatient hospital admission and
services provided from July 8, 2021, to July 23, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for hospital observation care provided from
August 20, 2021, to August 21, 2021.
You asked the Plan to waive the copayment for the hospital observation care. You say that you never left the
emergency room and were not admitted. The Plan denied your request. The Plan says you have been charged
the correct cost sharing amount.
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 $310
copayment per visit for outpatient hospital observation services.
The record shows that you were placed in observation care to evaluate your condition. Therefore, you have
been asked to pay a $310 copayment for the hospital observation care. The hospital observation care falls
within the Outpatient Hospital Observation 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 hospital observation care provided from August 20, 2021, to August 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the SelectMDx testing provided on August 31, 2021.
You asked the Plan to pay for the testing services. You say that the test helps predict the likelihood prostate
cancer will be found by a biopsy. The Plan denied your request. The Plan says screening services without a
valid medical diagnosis are not a benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.
The file does not show that the predictive testing was ordered for a specific medical problem. The records do
not show that the results of testing will impact clinical management. The test at issue in this appeal was
requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we
decided that the Plan does not have to pay for the SelectMDx testing provided on August 31, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on December 9,
2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says the denied codes remain not supported.
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 various denied codes are not supported in the medical record. Specifically, the place of service
on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim
reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a
doctor's office (POS 11). 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 laboratory services
provided to the enrollee on December 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the hip orthoses provided on March 23, 2021.
You asked the Plan to pay for the orthoses. The Plan denied your request. The Plan says the documentation did not sufficiently support the billed codes.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid physician order or relevant medical records which support medical necessity for the supplies provided in this case. In this case, the records provided do not substantiate the need for the orthoses. There is no mention of hip pain or injury, no clinical course, or functional limitations documented. Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the hip orthoses provided on March 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Sanexas device therapy and vitamin injections provided on August 17, 2021 and billed with CPT codes G0283, 97750, 96372, 97112, J3490, J3411, J3415, J3490, J7999 and 97016.

You asked the Plan to pay for the Sanexas device therapy and vitamin injections. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says Prolotherapy is not a Medicare covered benefit.

The Plan must follow Medicare rules. Medicare rules say that in order for physician-provided drugs to be covered, the medical records must document the name of the drug administered as well as the dosage. The rules also say that Medicare Part B pays for outpatient physical therapy services only if they are furnished by, or under the direct supervision of a physical therapist in private practice; or by, or incident to the service of a nurse practitioner (NP) or physician assistant (PA) only when that NP/PA may perform physical therapy services under State law. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Sanexas device therapy and vitamin injections have not been met. Specifically, payment for HCPCS/CPT codes 96372, J3490, J3411, J3415, J3490 and J7999 are not supported. Specifically, the record does not contain documentation of the dosage and type of drug administered in each injection, which is required by Medicare for these services to be reimbursed. Additionally, after review of the file and publicly available records, we find that the physical therapy services at issue in this case were rendered by an NP/PA who is not licensed to provide physical therapy in the State of Oklahoma. Therefore, we decided that the Plan does not have to pay for the Sanexas device therapy and vitamin injections provided on August 17, 2021 and billed with CPT codes G0283, 97750, 96372, 97112, J3490, J3411, J3415, J3490, J7999 and 97016.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the scaling and root planing (D4341) provided on October
13, 2021.
You asked the Plan to pay for the dental services. You say that the cleaning you received in 2019 was a regular
cleaning. You also say that the deep cleaning you received on the date of service in this case should be paid in
full. The Plan denied your request. The Plan says scaling and root planing is covered once every 3 years, per
quadrant. The Plan also says that the frequency limit has been exceeded.
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 and the service is listed as covered, the
frequency limit of once every 3 years, per quadrant, that is stated in the 2021 Evidence of Coverage has been
exceeded. The record shows that the Plan paid for scaling and root planing for the lower left and lower right
quadrants that you received on December 26, 2019, and for the upper left and upper right quadrants that you
received on December 30, 2019, less than 3 years ago. Therefore, we decided that the Plan does not have to pay
for the scaling and root planing (D4341) provided on October 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and
services provided May 8, 2021, to May 13, 2021.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you did not request
a private room. The Plan denied your request. The Plan says the copayment was 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 a $260
copayment for each day for days 1 to 6 for Medicare-covered hospital care.
You have been asked to pay a total of $1,300 ($260 copayment x 5 days = $1,300) for the inpatient hospital
services. the inpatient hospital services fall 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 the inpatient hospital admission and services provided May 8, 2021,
to May 13, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for self-administered drugs received from June 27, 2021, to June
30, 2021.
You asked the Plan to pay for the drugs. You say that this should be paid for. The Plan denied your request.
The Plan says this is not a covered benefit.
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 pay for self-administered drugs received
from June 27, 2021, to June 30, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug test (G0480) rendered by the out-of-network (OON)
provider on March 5, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of 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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan
does not have to pay for the drug test (G0480) rendered by the out-of-network (OON) provider on March 5,
2020.