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

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. You say that neither you nor your colleagues have experience in the 
administration of the Plan's preferred drugs. You say that your office does not have local representatives for 
these preferred medications who can answer your questions or offer in-service training. You say that, with the 
lack of experience, there is much higher risk for error due to the conversion of dosage units for these 
medications. The Plan denied your request.  The Plan says they don't have record from the prescriber showing that the enrollee has tried one of the preferred 
drugs or that the enrollee has medical reasons which prevent him from using the preferred drugs. 
 
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 Botox. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the Plan requires a trial of the drugs 
Dysport and Xeomin before they will approve the requested drug. The enrollee has not tried either of the 
preferred drugs. There is no evidence that these preferred drugs would be less effective or would have adverse 
effects for the enrollee. The Preferred drugs are FDA approved for the proposed indication. There is not 
sufficient evidence from direct comparison studies available to permit a conclusion that the requested drug 
would result in superior outcomes to the Plan's preferred medications. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shoulder elbow wrist hand orthosis (L3960) provided on 
September 17, 2021. 
 
You asked the Plan to pay for the shoulder elbow wrist hand orthisis. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says there is no 
evidence the enrollee's physician discussed the need for this orthosis. 
 
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 relevant medical records which support medical necessity for the supplies provided in this case. Specifically, the documentation submitted does not include any evidence that the enrollee's 
physician discussed a need for this orthosis. 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 
shoulder elbow wrist hand orthosis (L3960) provided on September 17, 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 from 
August 4, 2021, to August 8, 2021. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you cannot afford to 
pay the high-cost share. You also say that you believed the insurance company would pay because you had 
COVID-19. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. The Plan also says that there was no Health Plan waiver of copayment amounts due to COVID-19 for 
inpatient hospital services for the dates of service in question. 
 
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 $335 
copayment per day for days 1-6 for an in-network inpatient hospital stay. The Plan contract also says that there is no charge after day 6. 
 
The record shows there was no cost share waiver in place by the Plan during your inpatient hospital stay from 
August 4, 2021, to August 8, 2021. You have been asked to pay a total of $1,340, which is a $335 copayment 
per day for a four-day inpatient hospital stay ($335 copayment x 4 days = $1,340). There is no charge for the 
day of discharge. 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 from August 4, 2021, to 
August 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on July 16, 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 cannot be unbundled. 
 
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, we have confirmed that code 76376 is a column II code to column I code 71275. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for imaging services provided to the enrollee on July 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for DecisionDx Melanoma testing provided on December 23, 
2021. 
 
You asked the Plan to pay for genetic testing. You say that this test was ordered by the treating physician with 
the intent to use the results to inform treatment decisions. The Plan denied your request. The Plan says the 
denial of payment for this testing is correct, because this testing did not meet coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules state that molecular diagnostic tests used to assist in risk 
stratification of melanoma patients are only covered when certain 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 genetic testing. Our reviewer says that this 
testing does not meet the criteria for payment. Our physician reviewer found the documentation does not 
support that the enrollee had Stage T1b or above malignant melanoma, or Stage T1a with documented concern 
about microstaging. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pay for DecisionDx Melanoma testing provided on December 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for needle electromyography, each extremity (95886) provided 
August 5, 2021. 
 
You asked the Plan to pay for the chiropractic services. You say that you believe the services should be 
covered because you were told that you would have coverage for these services and the provider would not 
have an issue with performing the exam. The Plan denied your request. The Plan says this service is not 
covered when rendered by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for needle electromyography, each extremity (95886) provided August 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on May 21, 2021. You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the billed code 
cannot be verified. 
 
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. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. 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 drug testing services provided on May 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit (99214) provided on 
September 1, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $35 copayment for services obtained by a 
specialist, or under certain circumstances, treatment by a nurse practitioner or physicians assistant or other 
non-physician health care professionals in a specialists office. The plan benefit says your in-network 
maximum out-of-pocket amount is $6,700. This is the most you pay during the calendar year for covered 
Medicare Part A and Part B services received from network providers. 
 
You have been asked to pay a $35 copayment for the specialist office visit provided as you had not previously 
met the maximum out-of-pocket amount for this calendar year at the time of service. 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 office visit (99214) provided on September 1, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayments for the specialist office visits provided on July 2, 2021, 
and November 16, 2021. 
 
You asked the Plan to waive the copayments for the specialist office visits. You say that the provider was not 
able to go through with the surgery scheduled in December 2021. You also say these two previous visits with 
the provider were pointless. The Plan denied your request. The Plan says that you have been charged the 
correct cost sharing amount. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide the correct Evidence of Coverage (EOC) for 2021. 
Without the correct EOC we are unable to determine if the cost share applied is correct. Therefore, we decided 
that the Plan has to waive the copayments for the specialist office visits provided on July 2, 2021, and 
November 16, 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 comprehensive pharmacogenomic panel provided on 
September 3, 2021. 
 
You asked the Plan to pay for the comprehensive pharmacogenomic panel. You say that the medical records 
support the need for this testing. The Plan denied your request. The Plan says this panel was not billed 
correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that Pharmacogenetics testing will be considered 
medically reasonable and necessary only when the enrollee has a condition for which a certain medication is 
planned, but there are possible gene-drug interactions which must be ruled out. 
 
 
 We looked at the file and Medicare rules. The documentation does not show that this testing was performed in 
order to support treatment with any specific medication. This testing was done as a screening panel for multiple 
types of drugs. Based on this information, we decided that Medicare rules for coverage of the comprehensive 
pharmacogenomic panel have not been met. Therefore, we decided that the Plan does not have to pay for the 
comprehensive pharmacogenomic panel provided on September 3, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Omnipod. 
 
You asked the Plan to pre-approve the Omnipod. You say that the item should be covered. The Plan denied 
your request. The Plan says Your Medicare Advantage (MA) plan does not cover outpatient prescription drugs. 
 
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 the Omnipod.  
 
Benefits for the Omnipod 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower bone graft (21215) and a face bone graft 
(21210). 
 
You asked the Plan to pre-approve a lower bone graft and a face bone graft. You say that the enrollee has a life-
threatening infection coming from an upper dental implant. The infection spread through his entire oral cavity. 
You also say as a result of the infection and surgical procedures, the enrollee has suffered significant bone loss, 
and is missing all of his upper teeth and a majority of his lower teeth. You say the enrollee needs this procedure 
done to allow placement of either dental implants or dentures. The Plan denied your request. The Plan says the 
services requested are purely dental in nature. The Plan also says services are unrelated to the limited clinical 
indications. The services are not eligible for coverage under the medical benefit. 
 
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. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
lower bone graft (21215) and a face bone graft (21210).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on November 
7, 2021. 
 
You asked the Plan to waive the copayment for the urgent care visit. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 
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 $45 
copayment for Urgently needed services.  
 
 
  You have been asked to pay a $45 copayment for the urgent care visit. the urgent care visit falls within the 
Urgently needed services 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 urgent 
care visit provided on November 7, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a retroperitoneal ultrasound provided on 
November 22, 2021. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you do not understand why this 
was not covered. 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 $160 
copayment for in-network radiological diagnostic services, including ultrasounds.  
 
 The ultrasound is a covered service that has cost sharing. If the allowed amount is less than the cost sharing 
amount found in the EOC, you are responsible for the full allowed amount. You have been asked to pay the 
allowed amount of $120.15, which is less than the $160 copayment for an ultrasound. An ultrasound falls 
within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for a retroperitoneal ultrasound provided on November 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on November 5, 
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 a modifier was not billed on the claim to represent the services as separate/distinct. 
 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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for imaging services provided to the enrollee on November 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve rehabilitation services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve rehabilitation services. You say that this care is medically necessary. The 
Plan denied your request. The Plan says there are in-network providers available for your medical needs. 
 
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 
rehabilitation services to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cardiomyopathy Risk Panel provided on December 29, 
2020. 
 You asked the Plan to pay for the Cardiomyopathy Risk Panel. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says Medicare denies coverage for all 
cardiovascular risk assessment panels. 
 
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 test at issue in this appeal, the Cardiomyopathy Risk Panel, was requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. Additionally, the documentation submitted 
does not include any clinical information to determine why this testing was ordered or how the results will 
affect the member's treatment. Therefore, we decided that the Plan does not have to pay for the 
Cardiomyopathy Risk Panel provided on December 29, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on October 14, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the drug testing. You say that you disagree with the denied claim. The Plan 
denied your request. The Plan says no prior authorization was obtained. 
 
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 did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for drug testing provided on October 14, 2021, by an out-of-network 
(OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code 81479) provided on 
August 24, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. CPT code 81479 (1 unit) 
remains not supported. The place of service 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 Off Campus-Outpatient Hospital POS 19; therefore, the billed Current 
Procedural Terminology (CPT) code. It is noted multiple attempts were made to obtain additional information 
from the provider. Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT 
code 81479) provided on August 24, 2021.