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

 
We decided that the Plan does not have to waive the copayment for a CT scan (71250) provided on April 8, 
2021. 
 
You asked the Plan to waive the copayment for the CT scan. You say that the services should be covered as 
they were COVID-19 related. The Plan denied your request. The Plan says the cost-sharing applied correctly 
based on the services provided. 
 
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 $350 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
 
 
 You have been asked to pay a $180.58 copayment for a CT scan, which is less than the $350 stated in the 
Plans contract. There are no guidelines stating that CT scans performed due to COVID-19 related issues would 
be waived. CT scans 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 a CT scan (71250) provided on April 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided to the enrollee on October 19, 
2020 and billed under code 85060. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the provider did not bill as required by Medicare coding regulations. The Plan says that 
code 85060 denied for inappropriate place of service reported for physician interpretation. The claims show a 
Place of service (POS) code of 22. The PC/TC indicator of 8 for CPT code 85060 identifies payment may not 
be made if furnished to hospital outpatients or non-hospital patients.  
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate Place of Service codes. In this case, the POS code reported 
is not supported by the medical records reflecting the services provided. Medicare rules for coverage of these 
services have not been met. Therefore, we decided that the Plan does not have to pay for medical services 
provided to the enrollee on October 19, 2020 and billed under code 85060.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a duplex scan (93970) provided on 
September 30, 2021. 
 
You asked the Plan to waive the copayment for the duplex scan. You say that the services should be covered as 
you rarely use your insurance and it would cause a financial hardship. The Plan denied your request. The Plan 
says the cost-sharing applied correctly based on the services provided. 
 
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 $50 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
 
 
 
 You have been asked to pay a $50 copayment for a duplex scan. Duplex scans 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 a duplex scan (93970) provided on September 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for hearing aids provided on October 21, 2020. 
 
You asked the Plan to reimburse you for the hearing aids. The Plan denied your request. The Plan says you 
must select a device from the covered list available through our participating hearing aid supplier. Hearing aids 
may require prior authorization from our hearing supplier. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only through the Plans participating hearing aid supplier. 
 
We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided through the 
Plans participating hearing aid supplier. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse 
you for hearing aids provided on October 21, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 85060. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says code 85060 may not be paid if furnished to hospital outpatients or non-hospital patients. 
The claim shows the provider billed in a place of service of 23 Emergency Room/Hospital. A more appropriate 
code is used for this service. The Plan states a corrected code would be reviewed if submitted.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, this claim cannot be paid due to an error 
with the Place of Service code. Medicare rules for coverage of this service have not been met. Therefore, we 
decided that the Plan does not have to pay for medical services provided to the enrollee on October 1, 2021 and 
billed under code 85060.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0553). 
 
You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose 
monitor is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been 
met. 
 
 
 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not require 
frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this 
information, we decided that Medicare rules for coverage of the continuous glucose monitor have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (K0553).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair standard seat pan (E2231). 
 
You asked the Plan to pre-approve the wheelchair standard seat pan. You say that this accessory is medically 
necessary. The Plan denied your request. The Plan says this item is already allotted for in the approved base 
wheelchair and accessories. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee has already been approved a manual wheelchair base and wheelchair seat 
cushion. These items serve the same purpose as the requested seat pan. Therefore, we decided that the Plan 
does not have to pre-approve a wheelchair standard seat pan (E2231).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6531.  
You asked the Plan to pre-approve the compression stockings. You say that the stockings are medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6531 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. 
Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code 
A6531.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Foundation Once Liquid CDx panel provided on June 28, 
2021. 
 
You asked the Plan to pay for the Foundation One Liquid CDx panel. You say that you would like 
reconsideration because this testing was medically necessary. The Plan denied your request. The Plan says the 
member does not meet Medicare criteria for coverage. 
 
The Plan follows Medicare rules. Medicare rules say that NGS as a diagnostic laboratory test for patients with 
acquired (somatic) cancer are non-covered if the cancer patient does not meet the criteria noted in the Medicare 
rules section of this letter. 
 
 
  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 Foundation One Liquid CDx panel. Our 
reviewer says that there is insufficient documentation to support that the enrollee has either recurrent, relapsed, 
refractory, metastatic, or advanced stage III or IV cancer, and has decided to seek further cancer treatment. Our 
physician reviewer found the member does not meet Medicare criteria for coverage of this testing. 
 
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 Foundation One Liquid CDx panel have not been met. Therefore, we 
decided that the Plan does not have to pay for the Foundation Once Liquid CDx panel provided on June 28, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy assistant (PTA) services provided on 
June 22, 2021. 
 
You asked the Plan to pay for the PTA services. You say that this is medically necessary care The Plan denied 
your request. The Plan says the services are not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that the services of a PTA can only be billed incident 
to a therapist's services. 
 
 
 
 We looked at the file and Medicare rules. In this case, the billing provider is an NPP, not a therapist. This 
means that payment cannot be made for these services. Based on this information, we decided that Medicare 
rules for coverage of the PTA services have not been met. Therefore, we decided that the Plan does not have to 
pay for the physical therapy assistant (PTA) services provided on June 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyaluronan or derivative, hyalgan, supartz or visco-3, 
for intra-articular injection, per dose (CPT code J7321). 
 You asked the Plan to pre-approve the medication. You say that the medication is medically necessity for the 
enrollee's treatment for unilateral primary osteoarthritis in the right knee. The Plan denied your request. The 
Plan says the enrollee has not tried and failed the preferred step therapy (multi-injection) device(s): Orthovisc 
OR Supartz FX. The Plan states there is no indication our preferred agent(s) would likely be: less effective, 
and/or cause adverse effects for the enrollee. 
 
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 medication. Our physician reviewer 
found the enrollee has not tried and failed the required drug(s). The documentation does not support that 
Orthovisc or Supartz FX would likely be less effective, and/or would likely have adverse effects for the 
enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve hyaluronan or derivative, hyalgan, supartz or visco-3, for intra-articular injection, per dose 
(CPT code J7321).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee can tolerate and benefit from an 
intensive interdisciplinary treatment program. The Plan denied your request. The Plan says the denial of 
authorization for IRF service is correct. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
  
 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical, and rehabilitation needs does not 
require an acute rehabilitation hospital stay with an interdisciplinary approach to rehabilitation care. While the 
enrollee continues to have skilled therapy needs, there is no indication that the enrollee would require 
rehabilitation services of 15 hours per week under the supervision of a physician. Services can be provided at a 
lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dexamethasone sodium phosphate injections services 
(J1100, J3490) provided on November 19, 2020, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a dexamethasone sodium phosphate injections services. You say that the services 
a medically necessity. The Plan denied your request. The Plan says there was no prior authorization, and the 
member was referred by a non-participating provider. 
 
 
 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 a dexamethasone sodium phosphate injections 
services (J1100, J3490) provided on November 19, 2020, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that your provider advised that you can continue 
physical therapy which would be beneficial to recovery. The Plan denied your request. The Plan says the denial 
of authorization for SNF care is correct. 
 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you do not have daily skilled nursing needs 
that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have 
daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional 
therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled 
nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an MRI (72146) provided on November 1, 
2021. 
 
You asked the Plan to waive the copayment for the MRI. You say that the services should be covered. The Plan 
denied your request. The Plan says the cost-sharing applied correctly based on the services provided. 
 
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 $100 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
 
 
 
 
 You have been asked to pay a $100 copayment for an 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 
an MRI (72146) provided on November 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services coded as 80560. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says this code is not payable with Place of Service code 22. This code cannot be billed in an 
outpatient setting bill type. The Plan states this code is excluded from the laboratory fee schedule limitations 
and is paid under the Medicare physician fee schedule. A corrected claim would be required for review. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate place of service codes. In this case, this claim cannot be 
paid as billed due to the omission of the correct Place of Service code. Medicare rules for coverage of this 
service have not been met. Therefore, we decided that the Plan does not have to pay for medical services 
provided to the enrollee on October 19, 2021 under code 80560.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 92520.  
 
You asked the Plan to pay for code 92520. The Plan denied your request. The Plan says a National Correct 
Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between codes 92616 and 92520. This PTP 
edit has a modifier indicator of 0, which indicates there are no modifiers that are allowed with this code.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. In this case, this claim cannot be paid as billed due to 
a modifier issue with the codes billed and the edits in place by the Medicare billing guidelines. Based on this 
information, we decided that Medicare rules for coverage of code 92520 have not been met. Therefore, we 
decided that the Plan does not have to pay for medical services provided to the enrollee on July 1, 2021 and 
billed under code 92520.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional Modivcare mileage. 
 
You asked the Plan to pre-approve additional mileage. You say that the enrollee has a diagnosis that needs to 
be monitored regularly. The Plan denied your request. The Plan says the shortest route is 68.3 miles, and this 
will exceed your benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers up to 48 one-way trips and each one-way trip must not exceed 50 miles of driving 
distance.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, trips over 50 miles 
are not covered. Therefore, we decided that the Plan does not have to pre-approve additional Modivcare 
mileage.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve jaw surgery (21248). 
 
You asked the Plan to pre-approve the jaw surgery. You say that this procedure is medically necessary. The 
Plan denied your request. The Plan says the requested procedure is dental in nature and non-covered. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or 
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve jaw surgery (21248).