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

 
We decided that the Plan does not have to waive the copayment for the MRI provided on June 18, 2021. 
 
You asked the Plan to waive the copayment for the MRI. You say that the provider billed the service 
incorrectly and you should not be responsible. The Plan denied your request. The Plan says the copayment 
amount 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 $125 
copayment for advanced imaging services provided at an outpatient hospital setting.  
 
You have been asked to pay $125 for the MRI. The MRI falls 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 
the magnetic resonance  imaging (MRI) provided on June 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for occupational therapy exercises provided from 
December 1, 2021, through December 29, 2021. 
 
You asked the Plan to pay for occupational therapy exercises. The Plan denied your request. The Plan says with 
the information we have, we cannot determine how the member came to the servicing provider, or whether the 
services are medically necessary. 
 
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 occupational therapy exercises 
provided from December 1, 2021, through December 29, 2021 have been met. The medical records have not 
been provided. Therefore, we decided that the Plan does not have to pay for occupational therapy exercises 
provided from December 1, 2021, through December 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. You say that you would like the plan to reconsider their denial. The 
Plan denied your request. The Plan says the requested Botox is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Botox is only covered for certain indications. 
 
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 Botox. Our reviewer says that the 
documentation does not support that the requested Botox is medically reasonable or necessary. Our physician 
reviewer found the enrollee has a medical history of chronic pain due to myofascial pain syndrome and 
spondylosis and facet arthropathy with thoracic back spasms and neck pain. There is no documentation that the 
enrollee has a diagnosis/condition for which Botox is covered in the Local Coverage Determination (LCD). 
Based on the medical records provided and the Medicare-approved major drug compendia there is no 
documentation that the requested Botox meets Medicare criteria for medically necessary. Therefore, the 
enrollee does not meet criteria for the requested Botox.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service February 24, 
2022. 
 You asked the Plan to pay for procedure code 71045. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 71045 is bundled into payment for 
code 71046. 
 
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 71046. 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 71045 billed for date of service February 24, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient office visit (99214) provided 
on March 8, 2022. 
 
You asked the Plan to waive the copayment for the outpatient office visit. The Plan denied your request. The 
Plan says these services were medical in nature, and your Physician service benefit was applied. The Plan also 
says that this claim was processed with the correct 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 $35 
copayment for Medicare-covered vision services.  
 
 
  You have been asked to pay a $35 copayment for the outpatient office visit. This outpatient office visit falls 
within the Vision care benefit category. Since these services were for a medical condition of cataracts, the 
medical vision copayment applies. 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 outpatient office 
visit (99214) provided on March 8, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76942 billed for date of service February 24, 
2022. 
 
You asked the Plan to pay for procedure code 76942. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for procedure code 76942 is bundled into 
payment for code 49083. 
 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 76942 
is a column II code to column I code 49083. 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 76942 billed for date of service February 24, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wrist-hand orthosis (L3916) for the right hand provided on 
March 1, 2022. 
 
You asked the Plan to pay for a wrist-hand orthosis. You say that the item at issue was a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for payment for DMEPOS have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the information in 
the enrollees medical record adequately supports the medical necessity for the item. 
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. Specifically, the available medical records do not discuss the item at issue. Therefore, we decided 
that the Plan does not have to pay for a wrist-hand orthosis (L3916) for the right hand provided on March 1, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 27, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 the lab services provided on January 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair and attachments. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair and attachments. You say that this is medically 
necessary. The Plan denied your request. The Plan says that you do not have a medical diagnosis of 
neurological disease, myopathy or congenital skeletal deformity causing mobility limitation. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity. 
 
 The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy or 
congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a Group 3 
power wheelchair and attachments.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for chiropractic manipulative treatment 
provided on January 7, 2022, and January 17, 2022. We also decided that the Plan does not have to pay for the 
electric stimulation therapy provided on January 7, 2022, and January 17, 2022. 
 
You asked the Plan to waive the copayment for the chiropractic manipulative treatment. You say that you need 
these services so you don't get headaches. The Plan denied your request. The Plan says the claim was processed 
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 $20 
copayment for each Medicare-covered chiropractic visit. Your contract with the Plan clearly says the only 
covered chiropractic service is manual manipulation of the spine to correct subluxation. 
 
You have been asked to pay a $20 copayment for each chiropractic manipulative treatment. You are also 
responsible for the full cost of the electric stimulation therapy as it is not a covered service when provided by a 
chiropractor. This means that you have been asked to pay the correct amount based on your contract with the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for chiropractic manipulative 
treatment or pay for the electric stimulation therapy provided on January 7, 2022, and January 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a Medicare-covered, primary care doctor in 
office visit on February 28, 2022. 
 
You asked the Plan to waive the copayment for in-network primary care office visit. You say that when you 
signed up for this plan, you thought the copay amounts would be less. You feel you should not have to pay for 
the $5 copayment due to this. The Plan denied your request. The Plan says there is a $5 copayment for each 
Medicare covered, in network primary care doctor in-office visit. 
 
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 $5 copay 
for In-Network Physician/Practitioner.  
 
You have been asked to pay $5 copay for in-network primary care office visit. In-network primary care office 
visit falls within the In-Network Physician/Practitioner 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 fora Medicare-covered, primary care doctor in 
office visit on February 28, 2022.  
 
Your complaint about the insurance representative giving misinformation is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Ketoconazole shampoo. 
 
You asked the Plan to pre-approve Ketoconazole. You say that the requested treatment is a medical necessity 
for the enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered drugs 
have not been met. 
 
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 treatment with 
Ketoconazole shampoo.  
 Benefits for Ketoconazole 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 the FANCC genetic testing provided on December 15, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that the MolDX Team has determined that testing for 
the FANCC is not a Medicare benefit and is a statutorily excluded service. In addition to single gene testing, 
MolDX will also deny panels of tests that include the FANCC gene.  
 
We looked at the file and Medicare rules. Per LCA A53628, FANCC genetic testing is not a covered benefit. 
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 FANCC genetic testing provided on December 
15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia for procedures involving arteries of the upper leg 
(01270) provided on February 16, 2022. 
 
You asked the Plan to pay for anesthesia. You say that this service was billed appropriately and is supported in 
the medical record. The Plan denied your request. The Plan says the enrollee was registered inpatient status on 
the date in question, therefore the Place of Service (POS) code billed on this claim is inappropriate. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate POS code. 
 
This claim was billed with POS code 22 (on campus, outpatient hospital). We find that POS code 22 is not 
supported in the medical record for this claim. Specifically, the record indicates that the enrollee was admitted 
to the hospital from February 11, 2022, to February 24, 2022. This means that the appropriate POS code for the 
service at issue would be 21 (inpatient hospital). Based on this information, we decided that Medicare rules for 
coverage of anesthesia have not been met. Therefore, we decided that the Plan does not have to pay for 
anesthesia for procedures involving arteries of the upper leg (01270) provided on February 16, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vyvgart 20 mg/mL. 
 
You asked the Plan to pre-approve Vyvgart. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Vyvgart. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has a diagnosis of Myasthenia gravis, acetylcholine receptor antibody negative, 
with (acute) exacerbation. The Food and Drug Administration has not stated that the requested drug is indicated 
for the enrollee's condition. The Medicare approved drug compendia do not contain a supportive citation for the 
use of the requested drug in the enrollee's clinical situation. Therefore, the enrollee does not meet criteria for 
the requested drug. 
 
 
 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vyvgart have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vyvgart 20 mg/mL.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Wegovy. 
 
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 self-administered drugs are not covered. 
 
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 Wegovy.  
 
Benefits for these services 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transportation services (A0427, A0425) provided 
on April 5, 2021. 
 
You asked the Plan to pay for ambulance transportation. You say that the enrollee was moved from one 
hospital to another, so this service should be separately payable. The Plan denied your request. The Plan says 
the enrollee was admitted to the hospital from April 1, 2021, to April 6, 2021. There is no documentation to 
support that the enrollee was discharged or admitted to any hospital on the date of this transportation. 
Therefore, this service is considered patient transportation and is included in the payment to the hospital. 
 
The Plan must follow Medicare rules. Medicare rules say that once a beneficiary is admitted to a hospital, it 
may be necessary to transport the beneficiary to another hospital or site temporarily for specialized care while 
the beneficiary maintains inpatient status with the original provider. This movement of the patient is considered 
patient transportation and is covered as an inpatient hospital service under Part A and is not eligible for 
separate payment under Part B. 
 
We find that separate payment is not supported for the ambulance services at issue. Specifically, the record shows that the enrollee maintained inpatient status with the hospital on the date of 
transportation and was not discharged until April 6, 2021. This means that the transportation is considered 
patient transportation and is covered as an inpatient hospital service. Based on this information, we decided 
that Medicare rules for separate payment of ambulance transportation have not been met. Therefore, we 
decided that the Plan does not have to pay for ambulance transportation services (A0427, A0425) provided on 
April 5, 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 March 1, 
2022. 
 
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 code 70450 is bundled into payment for 
code 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 March 1, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya (J3245). 
 
You asked the Plan to pre-approve Ilumya. You say that the enrollee has been on Ilumya since September 16, 
2021, with good efficacy. The Plan denied your request. The Plan says this is not a buy and bill, and the 
provider plans to get this medication through the enrollee's specialty pharmacy. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Ilumya (J3245).  
 
 
 
 
 
 
 
 Benefits for Ilumya may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.