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

 
We decided that the Plan does not have to pre-approve Xifaxan 550mg tablets. 
 
You asked the Plan to pre-approve the Xifaxan tablets. You say that the enrollee would benefit from this 
treatment. The Plan denied your request. The Plan says this is an oral drug and cannot be covered by Medicare 
Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xifaxan 550mg tablets.  
 
Benefits for the Xifaxan tablets 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on September 
27, 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 the denied code remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 services have not been met. Specifically, this claim was billed with an office POS code. The 
records do not support that the sample was taken in an office setting. Therefore, we decided that the Plan does 
not have to pay for laboratory services provided to the enrollee on September 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on June 21, 
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 Current Procedural Terminology (CPT) code 0242U (1 Unit) remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 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 laboratory services provided to the enrollee on June 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Estradiol 1mg tablet medication. 
 
You asked the Plan to pre-approve this medication. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says this medication is not a covered benefit under the 
enrollee's contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs.  The self-administered drug requested here is not among the types which are covered by Medicare Part B. 
Therefore, we decided that the Plan does not have to pre-approve the Estradiol 1mg tablet medication.  
 
Benefits for this medication 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an MRI and a CT scan provided form 
March 9, 2021, to April 23, 2021. 
 
You asked the Plan to waive the copayments for an MRI and CT scan. You say that you do not understand the 
charges and have a limited income. The Plan denied your request. The Plan says the claims were processed 
correctly and you are 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). Your contract with the Plan clearly says that you must pay a $200 
copayment for complex radiology.  
 
You received an MRI on March 9, 2021. Therefore, you are responsible to pay the $200 copayment.  
 You received a CT scan on April 23, 2021. Therefore, you are responsible to pay the allowed amount of 
$152.78, which is less than the $200 copayment.  
 
The total amount you owe is: $352.78.  
 
You have been asked to pay the total copayment amount of $352.78 for an MRI and CT scan. An MRI and CT 
scan fall within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayments for an MRI and a CT scan provided form March 9, 2021, to 
April 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement prosthetic leg with advanced foot feature 
 
You asked the Plan to pre-approve a replacement prosthetic leg with advanced foot feature. You say that the 
proposed foot will meet the functional and medical needs for the enrollee. This foot provides features that are 
not available in a standard, non-computerized foot. The Plan denied your request. The Plan says the requested 
electric foot is not medically necessary at this time 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a replacement prosthetic leg with 
advanced foot feature. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the record sent by the provider 
indicates the enrolle is requesting a Triton Harmony prosthetic foot (which should be coded as L5987, L5986, 
and L5781). The review has determined that the request is not a covered benefit because the records indicate 
that the enrollee is requesting an electric foot, which is not covered by Medicare. Other records indicate that 
the enrollee may be requesting a Triton Harmony foot, but the enclosed records do not describe your functional 
level and thus is not medically necessary at this time. The medical records provided do not meet the 
requirements listed in the LCD for Medicare coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a replacement prosthetic leg with advanced foot feature have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a replacement prosthetic leg with advanced 
foot feature
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to 
the enrollee on September 17, 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 this should be reported with CPT 81479. 
 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 0037U is not supported in the medical record. Specifically, the testing at issue in this 
case should be reported with CPT 81479. 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 
Comprehensive Genomic Profile (CGP) testing provided to the enrollee on September 17, 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 28, 2021. 
 
You asked the Plan to pay for the office visit. You say that you were not aware this provider was not your 
doctor, and you were never told to seek another doctor. You say that you did nothing wrong, and the doctor 
should have sent you away if you weren't supposed to be there. The Plan denied your request. The Plan says in-
network providers were available. 
 
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 provided by an out-of-network 
provider on October 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram (93000) provided on 
November 3, 2021, 
 
You asked the Plan to waive the copayment for the electrocardiogram. You say that the services should be 
covered in full as you don't have a deductible. The Plan denied your request. The Plan says the cost-sharing 
applied correctly based on the services provided, the claim did not deny. 
 
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 $25 
copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
 You have been asked to pay a $17.84 copayment for an electrocardiogram, which is less than the standard $25 
copayment. Electrocardiograms fall within the Outpatient Diagnostic Tests and Therapeutic Services and 
Supplies benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for an electrocardiogram 
(93000) provided on November 3, 2021,
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 8, 
2021. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for this code is bundled into payment for 
70496. 
 
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 70450 
is a column II code to column I code 70496. 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 procedure code 70450 billed for date of service October 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) and the trigger point injection(s) 
(20553) rendered by the out-of-network (OON) provider on November 4, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. 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 the office visit (99214) and the trigger point injection(s) (20553) rendered by the 
out-of-network (OON) provider on November 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pantoprazole tablets. 
 
You asked the Plan to pre-approve Pantoprazole tablets. You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says Pantoprazole tablets are not covered under the 
enrollee's Medicare Part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Pantoprazole tablets.  
 
Benefits for Pantoprazole tablets 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 75mg Gemtesa Tablets. 
 
You asked the Plan to pre-approve the Gemtesa Tablets. You say that you would like reconsideration because 
the requested tablets are medically necessary. The Plan denied your request. The Plan says the requested drug 
is not covered under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve 75mg Gemtesa Tablets.  
 
Benefits for the Gemtesa Tablets 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network 
(OON) provider on January 11, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.  We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on January 11, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiac risk assessment genetic screening testing 
provided to the enrollee on March 19, 2021. 
 
You asked the Plan to pay for the testing. You say that this was medically necessary. The Plan denied your 
request. The Plan says the diagnosis code does not substantiate this service. 
 
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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there was no specific clinical rationale for the cardiac risk assessment genetic screening test. The 
documentation does not indicate how the test results will assist in managing the enrollee's condition. 
 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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the cardiac risk assessment genetic screening testing provided to the enrollee on March 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 CDx testing panel provided on July 19, 
2021. 
 
You asked the Plan to pay for the Guardant360 CDx panel. You say that POS code 81 is correct for use with 
this testing. The Plan denied your request. The Plan says the POS code does not match the location in which 
the specimen was taken. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 Guardant360 CDx panel 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 the Guardant360 CDx testing panel provided on July 19, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies (A6197) provided to the enrollee on 
October 26, 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 this code is always bundled into payment for other services not specified and no 
separate payment is made per Medicare. 
 
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 A6197 is "Alginate or other fiber gelling dressing, wound 
cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., each dressing."  
 
We find that CPT code A6197 is not supported in the medical record. Specifically, this code has a status 
indicator of "P." Payment for these sort of codes is always included in payment for other codes. 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 wound care supplies (A6197) provided to the enrollee on 
October 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Methodone assisted treatment (G2067) rendered by the 
out-of-network (OON) provider on March 22, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the Methodone assisted treatment (G2067) rendered by the out-of-network (OON) 
provider on March 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 30, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says you billed these services with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 June 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from  
April 20, 2021, through April 21, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says an 
inpatient admission was not medically necessary. 
 
 
 The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the record did not show that at the time of inpatient admission the admitting 
physician reasonably expected that the enrollees necessary hospital care (including earlier emergency 
department and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from April 20, 2021, through  
April 21, 2021.