Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve six (6) home PT visits. 
 
You asked the Plan to pre-approve six (6) home PT visits. You say that six (6) home PT visits are medically 
necessary. The Plan denied your request. The Plan says the enrollee could continue home exercise program 
going forward and that additional skilled therapy visits were not medically needed. You appeared fully capable 
of continuing your exercises on your own with/without help from a caregiver. Additional skilled home therapy 
visits were determined as not medically needed. 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 six (6) home PT visits. Our reviewer 
says that additional home PT is not medically necessary. Our physician reviewer found that based on the 
documentation provided, the health Plan's denial should be upheld. The enrollee does not have documented 
skilled therapy needs. The enrollee is functioning at a level commiserate with a lower level of care.  As such, 
the requested home health PT services are not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of six (6) home PT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve six (6) home PT visits.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is no need for daily skilled services. 
 
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 pre-approve the admission. Our reviewer says that 
the requested admission is not medically reasonable or necessary. Our physician reviewer found based on the 
medical records provided, there is no documentation that the enrollee requires skilled nursing services, i.e., the 
specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and 
effectively provide medically necessary and reasonable treatment. Daily skilled services are not required. The 
services are not required on an inpatient basis, only in a skilled nursing facility setting. Services in the long-
term care facility on a part time basis appear appropriate 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 the admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a topical application of fluoride varnish (D1206) provided on 
June 14, 2021. 
 
You asked the Plan to pay for a topical application of fluoride varnish. You say that you were supposed to see 
your in-network provider and you were assigned an out-of-network provider instead. You also say you are 
requesting reconsideration of payment. The Plan denied your request. The Plan says the service at issue is not a 
covered benefit whether you see an in-network or out-of-network 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, 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 topical application of fluoride varnish (D1206) 
provided on June 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing rendered on June 11, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
Guardant360 testing rendered on June 11, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound of the head and neck (76536) provided on April 21, 2021.
You asked the Plan to waive the copayment for an ultrasound of the head and neck. You say that you paid a $30 copayment at the time of service and do not understand the additional charge. The Plan denied your request. The Plan says the correct copayment was 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 $160 copayment for Medicare-covered radiological diagnostic services, not including X-rays. You have been asked to pay a $97.32 copayment for an ultrasound of the head and neck. An ultrasound of the head and neck falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. This means that you have been asked to pay less than or euqal to 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 ultrasound of the head and neck (76536) provided on April 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the respiratory viral pathogen testing by nucleic acid for 
cytomegalovirus, enterovirus, Herpes virus-6, Legionella pneumophila, and 12 other pathogens provided on 
March 4, 2021. 
 
You asked the Plan to pay for the multiple pathogen testing. You say that these services were medically 
necessary and should be covered. The Plan denied your request. The Plan says this was screening testing that is 
not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that multiplex panels for respiratory viral pathogens 
are limited to panels for 3-5 pathogens.  
 
We looked at the file and Medicare rules. The billed testing is for more than 6 pathogens. This is explicitly 
noncovered by the controlling LCD. Based on this information, we decided that Medicare rules for coverage of 
the multiple pathogen testing have not been met. Therefore, we decided that the Plan does not have to pay for 
the respiratory viral pathogen testing by nucleic acid for cytomegalovirus, enterovirus, Herpes virus-6, 
Legionella pneumophila, and 12 other pathogens provided on March 4, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound (76770), provided on June 7, 
2021. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that the service should be covered. The 
Plan denied your request. The Plan says the cost share was applied 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 $150 
copayment for Medicare-covered radiological diagnostic services.  
 
You have been asked to pay a $150 copayment for Medicare-covered radiological diagnostic services. An 
ultrasound falls within the outpatient diagnostic tests and therapeutic 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 the ultrasound (76770), provided on June 7, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve an oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve the oxygen concentrator. You say that the oxygen concentrator is medically 
necessary. The Plan denied your request. The Plan says that coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that oxygen is coverable when medically necessary for 
patients with significant hypoxemia who meet certain blood gas evidence requirements. In addition, the patient 
must have tried other alternative treatments without complete success. The patient must meet one of the 
following blood gas levels: 
 
1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 
 
2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during 
sleep for a patient who have hypoxia symptoms during sleep; 
 
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for 
patients who have hypoxia symptoms during exercise; 
 
4. Arterial PO2 between 56 and 59 mm Hg and arterial O2 saturation is 89% on room air if there is evidence of 
dependent edema, pulmonary hypertension, or erythrocythemia. 
 
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 oxygen concentrator. Our reviewer 
says that the oxygen concentrator is medically necessary. Our physician reviewer found the records show that 
any activity of minimal exertion, including walking less 10 feet, requires the enrollee to stop and catch his 
breath. The enrollee uses a CPAP machine at night. The review has determined that the coverage criteria for 
home oxygen therapy have been met. 
 
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 oxygen concentrator have been met. Therefore, we decided that the Plan has 
to pre-approve an oxygen concentrator (E1392).  
 
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for oral exam (D0120), initial periapical x-
ray (D0220), additional periapical x-ray (D0230), and bitewing x-rays (D0274) provided on March 8, 2021, by 
the out of network dentist. 
 
You asked the Plan to pay an additional amount for the dental services. You say that the dental office advised 
they were in network with your insurance. You say that the dentist wanted to do a deep cleaning. You say that 
you refused. You also say that you cannot afford to pay this bill. The Plan denied your request. The Plan says 1 
periapical x-ray is covered per calendar year. The Plan says that the frequency limit for this service has been 
exceeded. The Plan says there is a 50% coinsurance for the services in this case when they are received out of 
network. The Plan also says out of network providers 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 and the services are listed as covered, 
out of network dentists may bill you for any amount greater than what the plan pays. Additionally, 1 periapical 
x-ray is covered per calendar year. The record shows that the Plan paid for the initial periapical x-ray that you 
received on the date of service in this case. Therefore, we decided that the Plan does not have to pay an 
additional amount for oral exam (D0120), initial periapical x-ray (D0220), additional periapical x-ray (D0230), 
and bitewing x-rays (D0274) provided on March 8, 2021, by the out of network dentist.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (80048, 83880) provided on July 1, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that this was medically necessary. The Plan denied 
your request. The Plan says this was not authorized. 
 
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 laboratory services (80048, 83880) provided on 
July 1, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a continuous glucose monitor (CGM)(K0554, K0553) provided to the enrollee on April 5, 2021.
You asked the Plan to pay for the CGM. You say that the information is in the medical record. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay for a continuous glucose monitor (CGM)(K0554, K0553) provided to the enrollee on April 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the nebulizer (E0570), provided on April 1, 2021. 
 
You asked the Plan to pay for the nebulizer. You say that the item should be covered. The Plan denied your 
request. The Plan says while you can get your care from an out-of-network provider, the provider must be 
eligible to participate in Medicare. 
 
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 nebulizer (E0570), provided on April 
1, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on September 25, 2020.
You asked the Plan to waive the copayment for ambulance services. You say that you feel that the enrollee should not be responsible for the charges. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is being charged the correct 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $250 copayment for ambulance services. The enrollee has been asked to pay a $250 copayment for ambulance services. Ambulance services falls within the ambulance services 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 copayment for ambulance services provided on September 25, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 15, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not 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 laboratory services rendered on July 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on December 22, 2020. 
 
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 December 22, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided by an out-of-network 
provider on March 9, 2021. 
 
You asked the Plan to pay for the out-of-network physical therapy. The Plan denied your request. The Plan 
says out-of-network services were not authorized. 
 
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. 
Therefore, we decided that the Plan does not have to pay for physical therapy services provided by an out-of-
network provider on March 9, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 3, 2020. 
 
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 a nursing facility setting and 
should have been billed with POS code 31. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on July 3, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided by an in-
network provider on July 2, 2021. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that the neurosurgeon's 
Physician's Assistant conducted the entire examination (reading your Magnetic Resonance Imaging (MRI) and 
giving you medical advice). You say the Plan should not be paying doctors for services they do not render. You 
would like to be reimbursed for your $45 copayment. The Plan denied your request. The Plan says the claim 
was processed correctly, and the medical records show you were seen at a neurosurgery specialist's office. 
 
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 Physician Specialist Services.  
 
You have been asked to pay a $45 copayment for a specialist office visit. A specialist office visit falls within 
the Physician/Practitioner Services, Including Doctor's Office Visits benefit category. A Physician's Assistant 
can conduct specialist services on behalf of a medical doctor, with or without a medical doctor present. 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 specialist office visit provided by an in-network provider 
on July 2, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation (D7953) 
provided on May 19, 2021. 
 
You asked the Plan to pay for the bone replacement graft. You say that this procedure was necessary. The Plan 
denied your request. The Plan says the service requested is purely dental in nature, and there is no 
documentation of carcinoma or radiation treatment. The Plan also says that the service is unrelated to the 
limited clinical indications and is not eligible for coverage under the medical benefit. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the bone replacement graft for 
ridge preservation (D7953) provided on May 19, 2021.