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

We decided that the Plan does not have to pay for the definitive drug testing provided on November 20, 2020.
You asked the Plan to pay for the drug testing. You say that POS 81 is correct because the testing was
performed at the laboratory. The Plan denied your request. The Plan says Medicare rules say that laboratory
claims must report the POS code for the site where the sample was taken.
The Plan must follow Medicare rules. Medicare rules say that for 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. The documentation does not indicate this sample was taken by the
lab directly. As such, the use of POS code 81 is not supported. Based on this information, we decided that
Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not
have to pay for the definitive drug testing provided on November 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral hygiene instruction (D1330) and periapical x-rays (D0220, D0230) provided on October 7, 2021.
You asked the Plan to pay for the dental services. You say that you did not want x-rays because you only needed a consultation. You say that the provider insisted you needed x-rays. You say that you were advised the office refers out for prosthetic services. You also say that you received ineffectual over-service and should not be responsible. The Plan denied your request. The Plan says oral hygiene instruction and periapical x-rays are not listed as covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the oral hygiene instruction and periapical x-rays are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the oral hygiene instruction (D1330) and periapical x-rays (D0220, D0230) provided on October 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the anesthesia services rendered on May 27, 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 00952 is not separately payable.  

The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is always bundled into payment for other services not specified.  

We looked at the file and Medicare rules. Billed procedure code 00952 (anesthesia for vaginal procedures (including biopsy of labia, vagina, cervix or endometrium); hysteroscopy and/or hysterosalpingography) has a status indicator of B and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for the anesthesia services rendered on May 27, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the panel testing provided on July 29, 2021.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the documentation does not meet requirements.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
The file shows that the enrollee received urinary tract infection panel testing. We looked at the file and the rules. In this case, there are insufficient medical records to show that this testing was needed above the standard of care, urine culture. 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 panel testing provided on July 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injections (62320) provided October 25, 2021.
You asked the Plan to pay for the injections. You say that the injections were medically necessary. The Plan
denied your request. The Plan says the documentation does not support the billed services.
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is
due and the amount of payment.
We looked at the file and Medicare rules. No medical records were provided to support this service. Based on
this information, we decided that Medicare rules for coverage of the injections have not been met. Therefore,
we decided that the Plan does not have to pay for injections (62320) provided October 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the filter holder and integrated filter housing, breathing circuits, and tracheostomy tube collar/holder provided on March 1, 2021.
You asked the Plan to pay for the filter holder and integrated filter housing, breathing circuits, and tracheostomy tube collar/holder. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the items rendered are not supported by the documentation.
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 proof of delivery for the supplies provided in this case. The documentation submitted did not include a patient receipt or proof of delivery or documentation to show the items had been given to the enrollee. 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 the filter holder and integrated filter housing, breathing circuits, and tracheostomy tube collar/holder provided on March 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab services provided on July 23, 2021.  

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are not covered.  

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 testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on July 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider on April 9, 2021, to May 4, 2021.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you do not agree with this copayment. The Plan denied your request. The Plan says the correct copayment has been 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 $295 copayment per day for days 1-7. There is a $0 copayment for additional days for inpatient hospital care.
You have been asked to pay a $295 copayment per day for days 1-7. There is a $0 copayment for additional days for an inpatient hospital stay. The total amount you are being asked to pay is $2,065 ($295 x 7 days = $2,065). The correct copayment has been applied to the services that were provided. An inpatient hospital 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 inpatient hospital stay provided by a participating provider on April 9, 2021, to May 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rituxan Hycela for the enrollee.

You asked the Plan to pre-approve Rituxan Hycela. You say that this is medically necessary. The Plan denied your request. The Plan says that information shows that the enrollee has not tried Truxima.

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 Rituxan Hycela. Our reviewer says that Rituxan Hycela is not medically reasonable and necessary. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Rituxan Hycela. The documentation does not support that Ruxience and Truxima have been tried and failed. The documentation in the case file does not support that Ruxience and Truxima would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Rituxan Hycela have not been met. Therefore, we decided that the Plan does not have to pre-approve Rituxan Hycela for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on July 26, 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. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on July 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on October 12, 2021.  You asked the Plan to pay for the dental service. You say that this service should be covered. You say that you have gum disease. You say that your dentist wants you to have 4 cleanings per year. You say that this is necessary for your gums to be healthy. You also say that 2 cleanings per year is not enough. The Plan denied your request. The Plan says periodontal maintenance is covered once every 6 months. 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 periodontal maintenance is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for periodontal maintenance that you received on July 2, 2021. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on October 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam services and office visit
(76514, 99214, 92133) provided on September 22, 2021.
You asked the Plan to waive the copayment for the vision services. You say that this was a yearly check-up,
and you should not owe this copayment. 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 $50
copayment for each specialist's office visit for vision services.
You have been asked to pay a $50 copayment for the vision services provided in a specialist's office.
Documentation shows that the services in question were provided for medical purposes. 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 eye exam services and office visit (76514, 99214, 92133)
provided on September 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the oral exam (D0120), prophylaxis
(D1110), and vertical bitewings, 7 to 8 radiographic images (D0277), provided on July 14, 2021, by an out-ofnetwork
dentist.
You asked the Plan to pay an additional amount for the dental services. You say that you have special needs.
You say that your book of benefits says there is a $3,000 allowance. You say that you feel most comfortable
with this provider. You also say that this provider is most familiar with your needs. The Plan denied your
request. The Plan says vertical bitewings are not a covered service. The Plan also says that out of network
dentists may bill you for any amount greater than what the plan pays the provider.
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, vertical bitewing images are not
among those covered under this benefit. Additionally, out of network dentists may bill you for any amount
greater than what the plan pays the provider. Therefore, we decided that the Plan does not have to pay an
additional amount for the oral exam (D0120), prophylaxis (D1110), and vertical bitewings, 7 to 8 radiographic
images (D0277), provided on July 14, 2021, by an out-of-network dentist.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (10160-78) provided on May 10, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are not payable.

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 10160-78 is not supported in the medical record. Specifically, the records do not indicate that this service was rendered in the operating room. The billing of modifier -78 is not supported. 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 the services (10160-78) provided on May 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office services provided on August 12, 2021, by an out-ofnetwork
(OON) provider.
You asked the Plan to pay for the office services. You say that you saw this provider several years ago and they
were in-network. The Plan denied your request. The Plan says the services provided were from an out-ofnetwork
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 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 office services provided on August 12, 2021, by
an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the
enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary.
The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and
does not require transfer to an LTACH.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. The patient
appears to be improving and responding to treatment. He requires additional short-term acute care hospital
services that can safely be administered at the current facility for the time being. The patient does not require
services at the LTACH that are not already available at the current facility. Our physician reviewer found that
the enrollee's condition does not meet Medicare criteria for LTACH services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a periodontal scaling and root planing (D4341), intraoral
imaging (D0220), and bitewings (D2740) provided by an out-of-network provider June 8, 2021, to August 26,
2021.
You asked the Plan to pay for a periodontal scaling and root planing, intraoral imaging, and bitewings. You say
that you would like the Plan to pay for this. The Plan denied your request. The Plan says the services that were
provided are not covered services.
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, D0220 and D434 are not among those
covered under this benefit. D2740 is not covered when services are provided by an out-of-network provider.
Therefore, we decided that the Plan does not have to pay for a periodontal scaling and root planing (D4341),
intraoral imaging (D0220), and bitewings (D2740) provided by an out-of-network provider June 8, 2021, to
August 26, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room (ER) services rendered on July 30, 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 nto billed correctly.
The Plan must follow Medicare rules. The rules say that Current Procedural Terminology (CPT) modifier -25 should only be used on claims for evaluation and management (E/M) services, and only when these services are provided by the same physician (or same qualified nonphysician practitioner) to the same patient on the same day as another procedure or other service.
We looked at the file and Medicare rules. The file shows that billed procedure code 99283 (ER services) was not billed with the required -25 modifier. 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 emergency room (ER) services rendered on July 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a second opinion specialist office visit and treatment provided on July 27, 2021, to September 8, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for a second opinion specialist office visit and treatment. You say that you stated you were skeptical with what the contracted provider wanted to do, so you sought a second opinion. You also say that you were not aware you needed a referral. The Plan denied your request. The Plan says the services rendered were from a non-contracted provider. The Plan also says that the claims were denied due to no authorization or referral was requested by the contracted provider, and it was confirmed that the enrollee self-referred to the 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 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 a second opinion specialist office visit and treatment provided on July 27, 2021, to September 8, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zilretta.

You asked the Plan to pre-approve Zilretta. You say that Zilretta is medically necessary. The Plan denied your
request. The Plan says the use of this drug is supported if you have never received an injection with this drug.
This drug is not approved for repeat use.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and 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 Zilretta. Our reviewer says that Zilretta
is not medically necessary at this time. Our physician reviewer found the efficacy and safety of repeat
administration of Zilretta have not been demonstrated. Based on the medical records provided and the
Medicare-approved major drug compendia, there is no documentation that the repeat Zilretta injections meet
Medicare criteria as safe and effective for you.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Zilretta have not been met. Therefore, we decided that the Plan does not have to
pre-approve Zilretta.