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

 
We decided that the Plan does not have to pay for lab services (80061, 81000, 82310, 82550, 82565, 84520) 
provided September 18, 2020. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 
 
 
 
 We find that CPT codes 80061, 81000, 82310, 82550, 82565, and 84520 are not supported in the medical 
record. Specifically, the place of service listed on the claim form (81, laboratory) does not match the place of 
service detailed in the records (11, office setting). Based on this information, we decided that Medicare rules 
for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for 
lab services (80061, 81000, 82310, 82550, 82565, 84520) provided September 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit for a medical eye exam 
provided on April 20, 2021. 
 
You asked the Plan to waive the copayment for the office visit. You say that that the provider said not to worry 
about paying for follow up visit. The Plan denied your request. The Plan says the claim process with a $30 
copay due to a miscellaneous credit on the account at the provider's office. A specialist visit is covered with a 
$40 copay. 
 
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 Vision Care, Medicare covered eye exams to diagnose and treat eye conditions.  
 You have been asked to pay less than the $40 copayment for this office visit due to a miscellaneous credit on 
the account at the provider's office. The office visit falls within the Vision Care, Medicare covered eye exams 
to diagnose and treat eye conditions 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 office visit for a medical eye exam provided on April 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mental health services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve mental health services. You say that this is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says there are in-network providers available to 
treat the enrollee's condition. 
 
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 
mental health services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for COVID-19 vaccine services provided to the enrollee on 
March 16, 2021. 
 
You asked the Plan to pay for the services. You say that this should be covered under the enrollee's plan. The 
Plan denied your request. The Plan says this should be billed to Original Medicare. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the services. The 
Plan follows the same rules.  
 
 
 
 Current guidelines provide for payment for the COVID-19 vaccine. However, the guidelines stipulate that 
Original Medicare pays for this service, not the health plan. Therefore, we decided that the Plan does not have 
to pay for COVID-19 vaccine services provided to the enrollee on March 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing (0242U) provided on July 29, 2021. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like reconsideration because 
this service was billed correctly. The Plan denied your request. The Plan says this claim was billed with an 
inappropriate place of service code. 
 
The Plan must follow Medicare rules. Medicare rules say that or purposes of payment under the Medicare 
Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service. 
 
We find that CPT code 0242U is not supported in the record. Specifically, this claim was submitted with a 
laboratory place of service code while the records suggest that the member's face-to-face service was not 
rendered in a laboratory setting. Based on this information, we decided that Medicare rules for coverage of the 
Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
Guardant360 testing (0242U) provided on July 29, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided to the enrollee on May 28, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid by the Plan. The Plan 
denied your request. The Plan says Original Medicare is still responsible for payment under the fee-for-service 
benefit. The fee-for-service benefit covers costs both related and unrelated to the Hospice Diagnosis on the day 
of election until the enrollee is admitted into hospice facility care. This benefit also covers services after the 
enrollee revokes until the beginning of the next month. 
 
The Plan must follow Medicare rules. 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. This claim must be reviewed by Original Medicare before 
it can be reviewed by the Plan. Therefore, we decided that the Plan does not have to pay for medical services 
provided to the enrollee on May 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood smear (85060) provided on September 1, 2021. 
 
You asked the Plan to pay for the blood smear. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says this claim was billed with an inappropriate 
place of service code. 
 
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 85060 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT 
code 85060 has a Professional/Technical Component indicator of 8. The means that payment for this service is 
not made to hospital outpatients. The record shows that this claim was billed with place of service code 22 for 
On Campus-Outpatient Hospital. Based on this information, we decided that Medicare rules for coverage of the 
blood smear have not been met. Therefore, we decided that the Plan does not have to pay for the blood smear 
(85060) provided on September 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for eyeglasses provided on January 17, 2021. 
 
You asked the Plan to reimburse you for the eyeglasses. The Plan denied your request. The Plan says the 
member does not have out-of-network benefits. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan 
covers these services when purchased at a network optical provider. 
 We looked at the file and the Plan's rules. The file shows that the eyeglasses were not purchased from a 
network optical provider. Based on this information, we decided that the Plan's rules for coverage of the 
eyeglasses have not been met. Therefore, we decided that the Plan does not have to reimburse you for 
eyeglasses provided on January 17, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services (90834) provided on July 28, 2021. 
 
You asked the Plan to pay for psychotherapy services. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 The Plan must follow Medicare rules. Medicare rules say that the clinical psychologist or clinical social worker 
will attempt to consult with the enrollee's attending or primary care physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy services have not been met. Specifically, the provided records do not document an 
attempt to consult with, nor a referral from, the enrollee's attending or primary care physician. Therefore, we 
decided that the Plan does not have to pay for psychotherapy services (90834) provided on July 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on December 11, 2020. You asked the Plan to pay for the testing services. You say that the denial is inaccurate. The Plan denied your 
request. The Plan says the billed codes cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
The file shows that hereditary cardiovascular gene testing was provided. We looked at the file and the rules. 
The records do not show that the testing was ordered by the enrollees treating physician to treat a specific 
medical problem. The testing is not covered for screening services. For the testing billed with the -XS modifier, 
the records do not show that a distinct procedure was performed for each of these tests. 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 lab testing services provided on December 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676). 
 
You asked the Plan to pay for a pneumatic compression device. You say that the item is medically necessary. 
The Plan denied your request. The Plan says this is not a covered service. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0676).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) (K0554) and 
supplies (K0553), provided on September 17, 2022. 
 
You asked the Plan to pay for the CGM and supplies. You say that the items are medically necessary. The Plan 
denied your request. The Plan says the member received these items though an unsolicited call. 
 
The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone 
regarding the furnishing of a covered item except under specific circumstances. 
 
We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an 
unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the 
enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated 
regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the 
past 15 months. Based on this information, we decided that Medicare rules for coverage of the CGM and 
supplies have not been met. Therefore, we decided that the Plan does not have to pay for the continuous 
glucose monitor (CGM) (K0554) and supplies (K0553), provided on September 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit services (99202) provided on January 26, 
2021. 
 
You asked the Plan to pay for the office visit services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the office visit services (99202) 
provided on January 26, 2021 have been met. Therefore, we decided that the Plan does not have to pay for the 
office visit services (99202) provided on January 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel (0242U) billed 
on September 7, 2021. 
 
  You asked the Plan to pay for the targeted genomic sequence analysis panel (0242U). You say that this service 
is considered separate from the hospital encounter and place of service 81 is accurate. You say that the 
laboratory must bill directly for the service and the service should be paid. The Plan denied your request. The 
Plan says the place of service must reflect the location of the patient when the specimen was obtained. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules say that the Place of Service 
(POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service. 
 
In this case, the CPT Code Manual definition of code 0242U is targeted genomic sequence analysis panel, solid 
organ neoplasm, cell-free circulating DNA analysis of 55-74 genes, interrogation for sequence variants, gene 
copy number amplifications, and gene rearrangements. 
 
We find that CPT code 0242U is not supported in the medical record. Specifically, this claim was billed with 
the laboratory place of service code, but the records do not support the members face-to-face service was 
rendered at the laboratory. Based on this information, we decided that Medicare rules for coverage of the 
targeted genomic sequence analysis panel (0242U) have not been met. Therefore, we decided that the Plan does 
not have to pay for the targeted genomic sequence analysis panel (0242U) billed on September 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-ray services provided to the enrollee on October 5, 2021. 
 
You asked the Plan to pay for the services. You say that the claim should be reprocessed for reimbursement, 
according to the contract. The Plan denied your request. The Plan says Medicare does not pay separately for 
service, as it is included in another procedure code. 
 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 71045 
is a column II code to column I code 74022. 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 x-ray services provided to the enrollee on October 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on 
October 14, 2021. 
 
You asked the Plan to pay for the office visit. You say that the medical records support the medical necessity of 
the services provided. You say that the provider regularly complies with all administrative requirements for 
payment and payment should be reconsidered. The Plan denied your request. The Plan says this provider is not 
a network provider with the Plan and the services were not approved in advance. 
  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 the office visit provided by an out-of-network 
provider on October 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyeglasses and a routine ophthalmological examination 
including refraction provided on December 23, 2020. 
 
You asked the Plan to pay for the eyeglasses and a routine ophthalmological examination including refraction. 
The Plan denied your request. The Plan says that the Plan paid the maximum allowed amount per the enrollees 
vision benefits under claim EKJMM42K4 for date of service November 2, 2020. 
 
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 these services every year. 
 
We looked at the file and the Plan's rules. The file shows that the Plan paid the maximum allowed amount per 
your vision benefits under claim EKJMM42K4 for date of service November 2, 2020. Based on this 
information, we decided that the Plan's rules for coverage of the eyeglasses and a routine ophthalmological 
examination including refraction have not been met. Therefore, we decided that the Plan does not have to pay 
for eyeglasses and a routine ophthalmological examination including refraction provided on  
December 23, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services (G0483) provided on December 14, 
2020. 
 
You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says this claim was not billed with the 
appropriate place of service code.  
The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare 
Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting 
where the beneficiary receives the face to-face service. 
 
We find that CPT code G0483 is not supported in the record. Specifically, this claim was billed with the 
laboratory place of service code while the records suggest that the member's face-to-face service was not 
rendered in a laboratory setting. Based on this information, we decided that Medicare rules for coverage of the 
drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug 
testing services (G0483) provided on December 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve FreeStyle Lite Test Strips. 
 You asked the Plan to pre-approve FreeStyle Lite Test Strips. You say that this brand of test strips is medically 
necessary. The Plan denied your request. The Plan says there is no reason presented as to why the Plan's 
preferred would not be sufficient for this enrollee. 
 
The Plan follows Medicare rules. Medicare rules say that Plans may specify specific brands and manufacturers 
as preferred as long as the coverage criteria listed in the Medicare rules section have been 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 FreeStyle Lite Test Strips. Our reviewer 
says that the requested test strips are not medically reasonable and necessary over the Plan's preferred brand. 
Our physician reviewer found there is no data to suggest why this particular brand is needed for this patient and 
why her daily checking regimen could not be accomplished with the Plan's preferred brand. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of FreeStyle Lite Test Strips have not been met. Therefore, we decided that the 
Plan does not have to pre-approve FreeStyle Lite Test Strips.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has knee osteoarthritis. She 
has not tried and failed the Plan's required drugs, Orthovisc and Synvisc. The records do not show that the 
required drugs would be contraindicated or less effective; therefore, Euflexxa is not reasonable or medically 
necessary. 
 
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 Euflexxa.