Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
April 28, 2021, to November 22, 2021. 
 
You asked the Plan to pay for dental services. You say that you were unaware that the provider was not in-
network. The Plan denied your request. The Plan says dental services provided by an out-of-network provider 
are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers dental 
services when the services are provided by a participating provider.  
 
 
 
 
 
 
  
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of dental services have not been met. Therefore, we decided that the Plan does not have to pay for 
dental services provided by an out-of-network provider on April 28, 2021, to November 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for tooth extractions (D7210) provided by an out-of-network 
provider on December 20, 2021. 
 
You asked the Plan to pay for tooth extractions. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says the benefit limit for D7210 was met and exceeded. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers tooth 
extractions twice per calendar year. 
 
We looked at the file and Medicare rules. A 50% coinsurance has applied to D7210 for teeth #2 and #3. (%600 
x 50% = $300). D7210 for teeth #4, #13, and #32 have been denied due to the frequency limit for tooth 
extractions having already been met. Based on this information, we decided that the Plan's rules for coverage of tooth extractions have already been met. Therefore, we decided that the Plan does not have to pay for tooth 
extractions (D7210) provided by an out-of-network provider on December 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 11, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on July 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 16, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says you billed an incorrect place of service on the claim. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on August 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed and side rails. 
 You asked the Plan to pre-approve the requested items. You say that a hospital bed will keep her from falling. 
The Plan denied your request. The Plan says the enrollee does not require positioning that cannot be 
accomplished in an ordinary bed. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital is only covered under certain 
medical indications.  
 
We looked at review, the file, and Medicare rules. In this case, the medical records do not show that the 
enrollee requires frequent changes in body positions not feasible in an ordinary bed. Based on this information, 
we decided that Medicare rules for coverage of the requested items have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a semi-electric hospital bed and side rails.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge day management (99239) provided on 
July 31, 2021. 
 
You asked the Plan to pay for the evaluation and management service. You say that the services were 
medically necessary. The Plan denied your request. The Plan says the enrollees claim would be covered under 
Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the 
last day of the month in which hospice is revoked.  The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering services 
and to know proper billing procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the hospital discharge day management (99239) provided on 
July 31, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical pathology rendered on May 21, 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 the PC and TC for diagnostic services are separately 
payable when furnished in different payment localities. 
 
We looked at the file and Medicare rules. The file shows that the PC and TC were not performed in different 
payment localities.  
 
 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 surgical pathology rendered on May 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage for drugs or biologicals have not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, the case record indicates that the requested medication will be dispensed by a pharmacy and will 
be brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve treatment with Prolia (J0897).  
 
Benefits for Prolia 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for refill kit for an implantable pump (A4220) meloxicam 
Injection (J3490) morphine sulfate injection (J2274) clonidine hydrochloride injection (J0735) fentanyl citrate 
injection (J3010) provided August 17, 2021. 
 
You asked the Plan to pay for the implantable pump and injections. You say that medical records provided 
support the necessity of the services in dispute. The Plan denied your request. The Plan says the records do not 
support the service billed. 
 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 patient receipt, proof of delivery, or relevant medical records which support 
medical necessity for the supplies provided in this case. The record shows that the Plan made several attempts 
to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to 
pay for refill kit for an implantable pump (A4220) meloxicam Injection (J3490) morphine sulfate injection 
(J2274) clonidine hydrochloride injection (J0735) fentanyl citrate injection (J3010) provided August 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care services provided to the enrollee 
from December 16, 2021, to December 19, 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 this is not coded per Medicare guidelines. 
 
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 99232 is "Subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded 
problem focused interval history; An expanded problem focused examination; Medical decision making of 
moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the patient is responding inadequately to therapy or has developed a minor 
complication. Typically, 25 minutes are spent at the bedside and on the patient's hospital floor or unit." 
 We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the records do not contain clinical 
documentation to confirm the evaluation and management services performed were not related to the procedure 
CPT 44146. Therefore, these services cannot be reviewed. In some cases, evaluation and management services 
performed during the global period can be reported if for an unrelated service is performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for subsequent hospital care services provided to the enrollee from December 16, 2021, to 
December 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the contact lenses, scleral, gas permeable (V2531) provided 
on June 17, 2021. 
 
You asked the Plan to pay for the contact lenses. You say that these services are necessary due to a medical 
condition, and therefore should be covered by your medical benefits. The Plan denied your request. The Plan 
says This service is not covered by Medicare or the Plan. 
 
Medicare generally does not cover routine vision and eyewear services, and only offers coverage of eyeglasses 
or contact lenses following cataract surgery that includes insertion of an intraocular lens. The Plan offers a 
routine vision benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case.  
 
Though the Plan offers some additional vision benefits in excess of Medicare coverage, eyeglasses and contact 
lenses are not among the services covered by this benefit. Therefore, we decided that the Plan does not have to 
pay for the contact lenses, scleral, gas permeable (V2531) provided on June 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for long term EEG (electroencephalogram) monitoring, 
continuous recording, review by physician or other QHP (95718) provided on November 8, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the enrollee was being seen for epilepsy related to 
diagnosis. The claim is supported by the enrollee's medical records. Please review the claim with the attached 
medical records and process the claim for payment. The Plan denied your request. The Plan says enrollees 
must receive their medical services from an in-network provider with the exception being urgent or emergent 
services. Non-emergent services with non-contracted providers require prior authorization before services 
being rendered. 
 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 had network providers 
available who could have provided 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 long term EEG (electroencephalogram) 
monitoring, continuous recording, review by physician or other QHP (95718) provided on November 8, 2021 
by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan rendered on September 
16, 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 procedure code 70482 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 70470 (CT scan head/brain) and 70482 (CT scan of 
orbit/ear/fossa). Code 70482 is a column II code with a modifier indicator of 1 when billed with column I code 
70470. Code 70482 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan rendered on September 16, 
2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis. 
 
You asked the Plan to pre-approve Eliquis. You say that this drug is medically reasonable and necessary. The 
Plan denied your request. The Plan says this drug is not covered under the enrollee's medical 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 pre-approve Eliquis.  
 
 
 Benefits for Eliquis 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 specimen validity testing provided on September 13, 2021. 
 
You asked the Plan to pay for specimen validity testing. 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 billed code and modifier cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. The rules state that providers 
may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural 
service.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of specimen validity testing have not been met. Specifically, we find that the testing described by the 
billed code is considered specimen validity testing which is not separately payable. The medical records 
provided do not support the use of the -59 modifier. Therefore, we decided that the Plan does not have to pay 
for specimen validity testing provided on September 13, 2021.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for the compounded drug (J7999) provided on December 22, 2021. 
 
You asked the Plan to pay for the compounded drug. You say that you would like reconsideration because this 
service has been reported correctly. The Plan denied your request. The Plan says that an invoice is required for 
payment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code J7999 is supported in the record. Specifically, the claim includes a description of the 
compounded drugs with the specific milligrams. Additionally, the governing LCA includes the precise payment 
that is applied per milligram of each drug. The documentation submitted does not include any evidence of this 
claim being billed incorrectly. It is the burden of the Health Plan to substantiate their denial with evidence. In 
this case, the Plan's denial has not been substantiated so we must find in your favor. Based on this information, 
we decided that Medicare rules for coverage of the compounded drug have been met. Therefore, we decided 
that the Plan has to pay for the compounded drug (J7999) provided on December 22, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 20, 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 diagnosis code is not appropriate. 
 
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 services were not billed with an appropriate 
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 laboratory services 
rendered on August 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional inpatient hospital services. 
 
You asked the Plan to pre-approve additional inpatient hospital services. You say that the requested additional 
inpatient hospital services are medically necessary. The Plan denied your request. The Plan says the requested 
additional inpatient hospital services do not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that acute inpatient hospital services are covered if they are 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. The records show that your Medicare benefits for inpatient hospital 
days have been exhausted. Based on this information, we decided that Medicare rules for coverage of acute 
care hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve 
additional inpatient hospital services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme (Q0138). 
 
You asked the Plan to pre-approve Feraheme. You say that this drug is medically reasonable and necessary. 
The Plan denied your request. The Plan says step therapy criteria have not been met. 
 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 Feraheme. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found the Plan requires a 
trial of Infed and Venofer before they will approve the requested drug. In this case, the patient has not tried and 
failed the required drug(s). There is no documentation provided indicating that the plans required drug(s) 
would likely be less effective and/or likely have adverse effects for the 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 Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme (Q0138).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve routine transportation services. 
 
You asked the Plan to pre-approve routine transportation services. You say that this transportation is necessary 
for your condition. The Plan denied your request. The Plan says although routine transportation is covered, the 
distance in this situation exceeds the Plan's contractual obligation. 
 
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 Plans coverage rules apply in this 
case. The Plan covers routine transportation when the one-way distance to the destination does not exceed 50 
miles of driving distance. 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, the distance would 
exceed 50 miles. Therefore, we decided that the Plan does not have to pre-approve routine transportation 
services.