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

 
We decided that the Plan does not have to pay for a determination of refractive state (92015) provided on 
August 10, 2022. 
 
You asked the Plan to pay for a determination of refractive state (92015). You say that your visit with this 
provider was a routine visit, not a refraction. The Plan denied your request. The Plan says refractive services 
are not covered under your medical benefit plan.  
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers eye refractions only when rendered during a routine eye exam. 
 
We looked at the file and the Plan's rules. The Plan rules say that eye refractions are only covered during a 
routine eye exam. The record shows the refraction was performed with a medical diagnosis. Based on this 
information, we decided that the Plan's rules for coverage of a determination of refractive state (92015) have 
not been met. Therefore, we decided that the Plan does not have to pay for a determination of refractive state 
(92015) provided on August 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone marrow aspirate. 
 
You asked the Plan to pre-approve a bone marrow aspirate. You say that you are in pain and have been through 
all the necessary step therapies. The Plan denied your request. The Plan says medical studies haven't proven 
that the requested procedure is helpful for treatment of your health problem. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a bone marrow aspirate. Our reviewer 
says that a bone marrow aspirate is not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspirate remains experimental. More research is needed to show safety 
and efficacy of bone marrow aspirate when it is used as bone graft material. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a bone marrow aspirate.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 6, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you provided the services to the enrollee out of 
good faith, and you would like the claim paid. The Plan denied your request. The Plan says the rendering and 
referring providers are both OON providers and there was no approved authorization. Also, the service 
rendered was not urgent or emergent. 
 
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 an office visit provided on June 6, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on May 26, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
  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 visit provided on May 26, 2022, by an out-
of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a second unit of procedure code 93970 billed for date of service March 31, 2022.

You asked the Plan to pay for a second unit of code 93970. You say that this service was reported correctly and should be paid. The Plan denied your request. The Plan says the medical record provided supports only one unit of the requested service.

The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code.

We find that 2 units of CPT code 93970 are not supported in the medical record. The medical record only supports 1 unit of CPT code 93970. Based on this information, we decided that Medicare rules for coverage of a second unit of code 93970 have not been met. Therefore, we decided that the Plan does not have to pay for a second unit of procedure code 93970 billed for date of service March 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for surgical supplies/chemical agent provided 
on June 01, 2022. 
 
You asked the Plan to waive the coinsurance for surgical supplies/chemical agent. You say that you should not 
have to pay more than $100 for the test you received. The Plan denied your request. The Plan says this cost 
sharing was charged 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 20% 
coinsurance for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay 20% coinsurance for surgical supplies/chemical agent. This item/service 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 coinsurance for surgical supplies/chemical agent provided on June 01, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT scan for therapy guide provided on 
May 3, 2022. 
 
You asked the Plan to waive the copayment for a CT scan for therapy guide. You say that the scan was ordered 
by your provider as part of your treatment. You say that the Plan paid $0 towards the claim, and you would like 
a review. The Plan denied your request. The Plan says this cost sharing was charged 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 $60 
copayment for each Medicare-covered radiation therapy service.  
 
 
  You have been asked to pay $48.91, which is less than the standard $60 copayment for a CT scan for therapy 
guide. This item/service falls within 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 CT scan for therapy guide provided on May 
3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the general wheelchair seat cushion (E2601) and standard 
wheelchair (K0001) provided by a provider not enrolled in the Medicare program. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the provider is not enrolled in 
the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the general wheelchair seat cushion 
(E2601) and standard wheelchair (K0001) provided by a provider not enrolled in the Medicare program.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for eye surgery provided on April 27, 2022. 
 
You asked the Plan to waive the copayment for eye surgery. You say that this should be covered. The Plan 
denied your request. The Plan says this cost sharing was charged 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 $350 
copayment for Outpatient surgery in a hospital outpatient facility. 
 
You have been asked to pay a $350 copayment for eye surgery. This item/service falls within the Outpatient 
surgery in a hospital outpatient facility 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 eye surgery provided on April 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
June 8, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
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. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service June 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by an out-of-
network provider on July 20, 2022. 
 
You asked the Plan to pay for the dental services. You say that you did not know they were no longer in-
network. The Plan denied your request. The Plan says your benefit for the requested item or service has already 
been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 8, 2022. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by an 
out-of-network provider on July 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 14, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like the claim to be reprocessed and paid. 
You say that the services provided were medically necessary. The Plan denied your request. The Plan says an 
authorization was not obtained prior to office visit. 
 
  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 an office visit provided on June 14, 2022, by an 
out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic radiology services provided on February 15, 2022. 
 
You asked the Plan to pay for diagnostic radiology services. The Plan denied your request. The Plan says 
Medicare is the primary payer through the end of the month. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on February 14, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for diagnostic radiology 
services provided on February 15, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on  
February 7, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care. The Plan denied your request. The Plan says the 
member was enrolled in hospice on this date of service. 
 
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 subsequent nursing facility care provided on  
February 7, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular pathology procedure, level 4, hereditary
assessment for cardiac conditions (81403) provided May 24, 2020.

You asked the Plan to pay for the laboratory services. You say that please find attached medical records.
Kindly review and process the claim for payment at the earliest. The Plan denied your request. The Plan says
there is no Medicare benefit for screening cardiovascular risk assessment testing for asymptomatic patients.
Screening asymptomatic patients for cardiovascular risk is statutorily excluded by Medicare.

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 laboratory services, was requested solely for screening purposes. Medicare
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay
for molecular pathology procedure, level 4, hereditary assessment for cardiac conditions (81403) provided May
24, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for out-of-network home health services 
provided to the enrollee from January 19, 2022, to February 14, 2022. 
 
You asked the Plan to waive the coinsurance for the out-of-network home health services. You say that you 
were unaware that the facility was out-of-network, and the enrollee cannot afford the coinsurance. The Plan 
denied your request. The Plan says this cost sharing was charged 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a 40% coinsurance for out-of-network home health care.  
 
The enrollee has been asked to pay a 40% coinsurance for the out-of-network home health services. This 
item/service falls within the out-of-network home health care benefit category. This means that the enrollee has 
been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for out-of-network home health services provided to the enrollee from January 
19, 2022, to February 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory services provided on April 
22, 2022. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that you would like the 
copayment waived The Plan denied your request. The Plan says this cost sharing was charged 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 $10 
copayment for other Medicare-covered laboratory tests that are not FIT tests. 
 
You have been asked to pay a $10 copayment for the laboratory services. This item/service falls within the 
other Medicare-covered laboratory tests that are not FIT tests 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 laboratory services provided on April 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone growth device. 
 
You asked the Plan to pre-approve a bone growth device. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that Osteogenesis Stimulators are 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 pre-approve a bone growth device. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found not enough time 9 months has 
passed since the fracture. The diagnosis of nonunion is not clearly established. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a bone growth device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a bone growth device.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve microsatellite instability (MSI) analysis. We decided that the 
Plan does not have to pre-approve PIK3CA gene analysis.  
 
You asked the Plan to pre-approve microsatellite instability analysis (81301) and PIK3CA gene analysis 
(81309). You say that this testing is medically necessary. The Plan says that your records show that your cancer 
was diagnosed above age 70 and you do not meet the revised Bethesda Lynch Syndrome (LS) guidelines. 
 
We decided that the Plan has to pre-approve microsatellite instability (MSI) analysis.  
 
The Plan must follow Medicare rules. Medicare rules say that microsatellite instability analysis is considered 
medically necessary in individuals who have colorectal cancer (CRC) diagnosed in enrollee greater than 70 
years of age who meet the revised Bethesda Lynch Syndrome (LS) guidelines to guide therapeutic decision-
making 
 
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 for microsatellite instability analysis. Our reviewer 
says that this testing was medically necessary. Our physician reviewer found that per the National 
Comprehensive Cancer Network (NCCN) Guidelines for rectal cancer, MSI testing is recommended for all 
patients with colorectal cancer regardless of stage. This is to guide both therapeutic decision making and future 
screening. The service is reasonable and medically necessary. 
 
The file shows that you have a medical indication for which Medicare will cover microsatellite instability 
analysis. Therefore, we decided that the Plan has to pre-approve microsatellite instability (MSI) analysis.  
 
We also decided that the Plan does not have to pre-approve PIK3CA gene analysis. 
 
The Plan follows Medicare rules. Medicare rules say that genes listed under Tier 2 Non-covered Codes/Gene 
Combinations are unlikely to impact therapeutic decision making in the clinical management of a patient. 
 
PIK3CA is listed under Tier 2 Non-covered Codes/Gene Combinations in LCD L35000. This means that this 
service is considered automatically denied as not medically necessary. Based on this information, we decided 
that Medicare rules for coverage of PIK3CA testing have not been met. Therefore, we decided that the Plan 
does not have to pre-approve PIK3CA gene analysis. 
 
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.