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

 
We decided that the Plan does not have to pay for the Shingles vaccine you received on May 17, 2022. 
 
You asked the Plan to pay for the Shingles vaccine. You say that your doctor recommended this shot to you 
and you assumed it would be covered by insurance. The Plan denied your request. The Plan says this vaccine is 
not covered under your medical benefits. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Shingles 
vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed 
to any illness related to the Shingles vaccine. Therefore, we decided that the Plan does not have to pay for the 
Shingles vaccine you received on May 17, 2022.  
 
Benefits for the Shingles vaccine 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 waive the coinsurance for an eye exam for a new patient and a 
determination of refractive state provided on March 18, 2022. 
 
You asked the Plan to waive the coinsurance for an eye exam for a new patient and a determination of 
refractive state. You say that the services per the EOC should be covered without a copayment for a routine eye 
exam not covered by Medicare. You also say that the Plan also includes a vision hardware benefit. The Plan 
denied your request. The Plan says you were 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 40% 
coinsurance for out-of-network services for the diagnosis and treatment of diseases and injuries of the eye.  
 
   
You have been asked to pay $78.96 in coinsurance, which is 40% of the allowed amount for an eye exam for a 
new patient and a determination of refractive state ($197.38 allowed amount x 40% coinsurance = $79.86). An 
eye exam for a new patient and a determination of refractive state fall within the vision 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 coinsurance for an eye exam for a new patient and a determination of 
refractive state provided on March 18, 2022.
Appeal type: Drugs
Decision: Unfavorable

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

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service December 
28, 2021. 
 
You asked the Plan to pay for procedure code 99100. You say that the claim should be reviewed and 
reprocessed based on the medical records. The Plan denied your request. The Plan says procedure code 99100 
is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
  We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service December 28, 2021.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for home health services provided from March 1, 2021, to March 31, 2021. 
 
You asked the Plan to pay for home health services. You say that you have tried to get the provider to bill a 
corrected claim. The Plan denied your request. The Plan says that this was billed with a missing CPT code, and 
the Plan is not responsible for balance billing. 
 
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. Although the Plan states that these services were not billed correctly, the 
submitted documentation did not include a claim showing how these services were billed. Without this 
information, the Plans denial cannot be verified. Therefore, we decided that the Plan has to pay for home 
health services provided from March 1, 2021, to March 31, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) of abdomen (74018) 
provided on April 6, 2022. 
 
You asked the Plan to pay for the CT. You say that the claim should be paid. The Plan denied your request. The 
Plan says the claim processed correctly. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan directed the 
provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible 
for the CT until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan 
does not have to pay for the computed tomography (CT) of abdomen (74018) provided on April 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 9, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. 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, 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. 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 February 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Aurora Zip Fusion device for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that unproven and not medically necessary procedures are not covered 
by Medicare due to insufficient evidence of efficacy. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The Aurora Zip 
fusion device is experimental. More research is needed to show safety and efficacy. Our physician reviewer 
found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Aurora Zip Fusion device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prefabricated abutmentsincludes modification and 
placement (D6056 x 2) and the implant supported porcelain/ceramic crowns (D6065 x 2). 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says these items are not covered under your contractual policy. 
 
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 dental items are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
prefabricated abutmentsincludes modification and placement (D6056 x 2) and the implant supported 
porcelain/ceramic crowns (D6065 x 2).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99215) provided on April 15, 2022 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the physician service. You say that the service was medically necessary. The 
Plan denied your request. The Plan says the service was not urgent or emergent in nature. 
 
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 the office visit (99215) provided on April 15, 2022 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder Detect testing (0012M) provided April 1, 
2022. 
 
You asked the Plan to pay for the Cxbladder Detect testing. You say that this test is medically necessary and 
covered. The Plan denied your request. The Plan says this testing is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder Detect testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the Cxbladder Detect testing (0012M) provided April 1, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the pulp caps-indirect (excluding final restoration) (D3120 x 2), core 
buildups, including any pins when required (D2950 x 2), and the porcelain/ceramic crowns (D2740 x2) 
provided on July 5, 2022. 
 
You asked the Plan to pay for these dental items. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that these dental items are not covered under 
your contractual policy. 
 
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. Specifically, the Evidence of Coverage (EOC) contract for the 2022 calendar 
year has not been provided. We are unable to determine your dental benefit coverage in this case. The Plan has 
not substantiated their denial issued; therefore, we must find in your favor. Therefore, we decided that the Plan 
has to pay for the pulp caps-indirect (excluding final restoration) (D3120 x 2), core buildups, including any 
pins when required (D2950 x 2), and the porcelain/ceramic crowns (D2740 x2) provided on July 5, 2022.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of lower extremity 
(73719). 
 
You asked the Plan to pre-approve an MRI of lower extremity. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the service at issue is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
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 an MRI of lower extremity. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the record indicates 
that the enrollee has pain in multiple joints. The record documents that the enrollee has decreased weight 
bearing but there are no red flag symptoms. Physical examination is noted to document full range of motion for 
which the enrollee has been receiving treatment. The requested service is not medically necessary and 
reasonable for the diagnosis and treatment for the enrollee's clinical condition at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of lower extremity have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a magnetic resonance imaging (MRI) of lower extremity (73719).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for remote electrocardiogram (ECG) 
monitoring and recording provided on July 7, 2022. 
 
You asked the Plan to waive the copayment for the remote ECG monitoring and recording. You say that you 
feel the provider is balance billing you. The Plan denied your request. The Plan says you were charged this cost 
sharing 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 $40 
copayment for each specialist visit.  
 
The file shows that the Plan processed a separate claim for the office visit for $31.80. For the ECG monitoring 
and recording, you have been asked to pay the remaining $8.20 to meet the $40 total copayment for the 
specialist visit. The visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits 
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 remote electrocardiogram (ECG) 
monitoring and recording provided on July 7, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care services coded 99222 provided on 
September 12, 2021. 
 
You asked the Plan to pay for the initial hospital care services. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 99222 is not supported in the medical record. Specifically, the claim shows that this 
service was billed with a place of service 21 (inpatient). However, the documentation supports that the enrollee 
was outpatient for this date of service. This means this code was billed with an incorrect place of service. Based 
on this information, we decided that Medicare rules for coverage of the initial hospital care services have not 
been met. Therefore, we decided that the Plan does not have to pay for the initial hospital care services coded 
99222 provided on September 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown porcelain/ceramic (code D2740) provided on 
May 18, 2022. 
 
You asked the Plan to pay for a crown porcelain/ceramic. You say that the crown was necessary due to gingival 
and periodontal problems between tooth 14 and 15. The Plan denied your request. The Plan says the services 
provided were not due to dental disease and are not a covered dental 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 pay for a crown 
porcelain/ceramic (code D2740) provided on May 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 19, 2021 billed with 
codes 81223, 81226, 81225, 81335, 81227, 81230, 81241, 81291 and 81240. 
 
You asked the Plan to pay for the genetic testing billed. You say that per the denial received from the Plan, 
medical records is required for processing of this claim. The Plan denied your request. The Plan says does not 
meet Medicare NCD/LCD criteria. 
 The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
October 19, 2021 billed with codes 81223, 81226, 81225, 81335, 81227, 81230, 81241, 81291 and 81240.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from December 27, 2021, to December 31, 2021. 
 You asked the Plan to pay for SNF care. You say that this was medically necessary. The Plan denied your 
request. The Plan says there was no daily skilled nurse or therapist need. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that there were no identifiable skilled nursing or skilled therapy service needs. The 
enrollee did not require skilled nursing or therapy services on a daily basis. The enrollee did not meet severity 
of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) services provided to the enrollee from December 27, 2021, to 
December 31, 2021.