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

 
We decided that the Plan does not have to reimburse you for the at-home COVID-19 test kit purchased on 
January 22, 2022. 
 
You asked the Plan to reimburse you for the at-home COVID-19 test kit. You say that you would like to be 
reimbursed for the at-home COVID-19 test kit you purchased. The Plan denied your request. The Plan says this 
test kit was purchased prior to the Plan's supplemental benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare will provide coverage for up to eight 
over-the-counter COVID-19 test each calendar month. The Plans contract states that effective February 1, 
2022, the Plan will provide coverage for up to eight over-the-counter at-home COVID-19 test kits per member 
 We looked at the file and Medicare rules. In this case, the record confirms that when the at-home COVID-19 
test kit was purchased on January 22, 2022, the Plans supplemental benefit for tests had not yet gone into 
place. Based on this information, we decided that Medicare rules for coverage of the at-home COVID-19 test 
kit have not been met. Therefore, we decided that the Plan does not have to reimburse you for the at-home 
COVID-19 test kit purchased on January 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0180 billed as a telehealth service for date 
of service November 10, 2021. 
 
You asked the Plan to pay for procedure code G0180. You say that these services were medically necessary 
and provided in good faith. The Plan denied your request. The Plan says this code is not a payable telehealth 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare publishes a list each year of codes 
payable when furnished via telehealth.  Only those services listed are payable telehealth services. Procedure 
code G0180 is not listed as a payable service when performed as a telehealth service. The Plan has made 
multiple outreach attempts to try to get a corrected claim from you to no avail. Based on this information, we 
decided that Medicare rules for coverage of procedure code G0180 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code G0180 billed as a telehealth service for date of service 
November 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on October 5, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says payment for the denied codes is bundled into payment for other codes. 
 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 87651 
is a column II code to column I code 87801. Additionally, code 87150 is a column II code to the column I code 
87500. 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 laboratory services provided to the enrollee on October 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiation therapy management (77499). 
 
You asked the Plan to pre-approve radiation therapy management. You say that the requested radiation therapy 
is medically necessary. The Plan denied your request. The Plan says the requested radiation therapy does not 
meet criteria. 
 
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 radiation therapy management. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found while he does not think that proton therapy is an experimental therapy, any 
potential benefit or detriment of proton therapy over standard IMRT is an investigational question. There are no 
compelling data to suggest that proton therapy is superior to or more beneficial than IMRT/IGRT. The 
generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, 
and to not routinely offer it to patients. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiation therapy management have not been met. Therefore, we decided that 
the Plan does not have to pre-approve radiation therapy management (77499).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (27130, 20985) provided November 10, 
2021. 
 
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the records do 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 code 27130, & 20985 is not supported in the medical record. Specifically, the operative 
report does not describe the services billed being performed. Based on this information, we decided that 
Medicare rules for coverage of the surgical services have not been met. Therefore, we decided that the Plan 
does not have to pay for surgical services (27130, 20985) provided November 10, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy visits. 
 
You asked the Plan to pre-approve the visits. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no documentation of an active or acute on chronic condition that would 
necessitate a new program. 
 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 the visits. Our reviewer says that the 
requested visits are not medically reasonable or necessary. Our physician reviewer found that the enrollee does 
not have documented ongoing home health physical therapy needs. The enrollee is functioning at a level 
commiserate with a lower level of care (i.e., home exercise program, outpatient therapy, layperson 
supervision).  As such, the requested ongoing 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 the visits have not been met. Therefore, we decided that the Plan does not have 
to pre-approve home health physical therapy visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation. 
 
You asked the Plan to pre-approve percutaneous vertebral augmentation. 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 PVA (percutaneous vertebroplasty (PVP) or 
kyphoplasty (PKP)) is 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 percutaneous vertebral augmentation. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the records do 
not show that the fracture is less than 6 weeks old. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous vertebral augmentation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve percutaneous vertebral augmentation.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve panniculectomy. 
 
You asked the Plan to pre-approve panniculectomy. 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 Palmetto GBA considers panniculectomy 
experimental and investigational for minimizing the risk of hernia formation or recurrence. 
 
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 panniculectomy. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the documentation does not support 
that the coverage criteria have been met in this case. It is not documented that the enrollee's panniculus hangs 
below the level of the pubis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of panniculectomy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve panniculectomy.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Procrit (epoetin alfa) injections. 
 
You asked the Plan to pre-approve the Procrit injections. You say that it is felt that this treatment is needed due 
to hemolytic anemia. The Plan denied your request. The Plan says this is not medically necessary as the 
preferred drug, Aranesp would likely be as safe and effective. 
 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 the Procrit injections. Our reviewer 
says that the requested drug is not considered medically reasonable and necessary based on step therapy 
criteria. Our physician reviewer found the record indicates that the enrollee has anemia of chronic kidney 
disease. The requested medication is a new start. The provided records do not indicate that the enrollee has 
tried and failed the plan's preferred step one alternative, Aranesp (darbepoetin alfa). The record does not 
indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's preferred 
step one alternative. The elements of the coverage criteria are not satisfied.  
 
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 Procrit injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Procrit (epoetin alfa) injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hepatitis c antibody screening (G0472) provided on 
October 11, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the the hepatitis c antibody screening. You say that the services should be 
covered as you disagree with the denial. The Plan denied your request. The Plan says the services denied 
correctly as they were non-emergent and prior authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan 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 hepatitis c antibody screening (G0472) 
provided on October 11, 2021 by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not 
meet criteria. 
 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 continued SNF care. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found records do not document the need for 
intravenous medications, new tube feeding, ostomy care, daily complex wound care or respiratory care. There 
is no documentation that daily skilled services are required. Although records document you are still limited 
functionally, provided records do not document a significant decline in your functional status compared to your 
recent baseline to necessitate further daily inpatient skilled therapy services. Records do not document that 
services in the home with home health care or in a long-term care facility on a part time basis are not 
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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (G0482) provided on January 19, 2022 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and prior authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan 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 (G0482) provided on January 
19, 2022 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a specialist office visit provided on 
October 19, 2021. 
 
You asked the Plan to waive the coinsurance for the specialist visit. You say that  The Plan denied your 
request. The Plan says the enrollee has been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a 4% coinsurance for primary care or specialist visits.  
 
The enrollee has been asked to pay $5.31, which is 4% of the allowed amount for the specialist visit ($132.79 
allowed amount x 4% coinsurance = $5.31). The specialist visit falls within the Physician/Practitioner Services, 
Including Doctor's Office Visits 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 a specialist office visit provided on October 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (procedure code 84466) provided to the 
enrollee on March 23, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this is not a covered benefit. 
 
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, the CPT Code Manual definition of code 84466 is "Transferrin." 
 
We find that CPT code 84466 is not supported in the medical record. Specifically, this code has a status 
indicator of "X" which means that it is statutorily excluded. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for laboratory services (procedure code 84466) provided to the enrollee on March 23, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation services 
(A0428, A0425) provided on December 7, 2021. 
 
You asked the Plan to waive the copayment for ambulance transportation. You say that you feel you should not 
be responsible for this charge. The Plan denied your request. The Plan says this claim was processed correctly, 
and your copayment was assessed in accordance with your contract. Ambulance services require a $150 
copayment. 
 
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 ground ambulance services.  
 
You have been asked to pay a $150 copayment for ambulance transportation. 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 ambulance transportation services (A0428, A0425) provided on December 7, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided from February 19, 2021, to 
April 15, 2022. 
 
You asked the Plan to pay for the physician's services. You say that no one told you these doctors were not 
participating with the Plan. The Plan denied your request. The Plan says you must receive your care from a 
network provider. In most cases, care you receive from an out-of-network provider will not be covered. 
 
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 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided from February 19, 2021, to 
April 15, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation (A0427, 
A0425) provided on January 7, 2022. 
 
You asked the Plan to waive the copayment for ambulance transportation. You say that you had been 
hospitalized until the day before and live very close to the hospital. You cannot afford this bill. The Plan denied 
your request. The Plan says this claim was processed correctly, and your copayment was assessed in 
accordance with your contract. 
 
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 $250 
copayment for Medicare-covered ambulance services.  
 
You have been asked to pay a $250 copayment for ambulance transportation. 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 ambulance transportation (A0427, A0425) provided on January 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 vaccine provided on November 26, 2021. 
 
You asked the Plan to pay for the COVID-19 vaccine. You say that you have not been paid anything for this 
service. The Plan denied your request. The Plan says it is not responsible for paying this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare Advantage patients vaccinated in 
2021, providers should submit COVID-19 vaccine administration claims to Original Medicare through their 
respective Medicare Administrative Contractor (MAC). In this case, the COVID-19 vaccine was provided to 
this Medicare Advantage patient in 2021.  This means that the claim for this service needs to go to Original 
Medicare, not the member's Medicare Advantage Plan, for payment. You incorrectly submitted this claim to 
the Plan for payment. It should be noted that in 2022, the rule has changed, and COVID-19 vaccines are now 
paid by the Plan directly.  However, because this vaccine occurred in 2021, you need to submit the claim to 
Original Medicare. Therefore, we decided that the Plan does not have to pay for the COVID-19 vaccine 
provided on November 26, 2021.