Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete series of x-rays (D0210) and unspecified 
preventative procedure (D1999) provided on January 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that your provider assured you that these services 
would be covered. You cannot afford these bills. The Plan denied your request. The Plan says these services are 
not covered by your dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
complete series of x-rays (D0210) and unspecified preventative procedure (D1999) provided on January 13, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four (4) additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve additional PT visits. You say that you want to go back to a physical 
therapist because you get back pain when you do your home exercises. The Plan denied your request. The Plan 
says the requested physical therapy is not medically necessary. Functional improvements are not expected at 
this time, and you can do a home exercise program. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 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 additional PT visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that based on the available records, you appear to have improved with 
therapy to the point of being able to perform exercises on your own. Further skilled therapy at this point does 
not appear to be necessary to achieve significant improvement in your symptoms or functional status. Further 
utilization of the home exercise program appears appropriate at this point.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve four (4) additional physical therapy (PT) visits.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport (A0428) and ground mileage (A0425) provided on November 2, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that the transport was medically necessary. The 
Plan denied your request. The Plan says the ambulance services were not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance services. Our reviewer says 
that the ambulance services were not medically necessary. Our physician reviewer found a prudent layperson 
would not believe that immediate medical attention was required for someone who was being discharged to 
home. Therefore, the reviewer found that the ambulance services were not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan 
does not have to pay for the ambulance service, basic life support, non-emergency transport (A0428) and 
ground mileage (A0425) provided on November 2, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Mental Health Services provided on December 
29, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Outpatient Mental Health Services. You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says the provider is out-of-network and it 
was determined these services were not urgent or emergent. 
 
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 Outpatient Mental Health Services provided on 
December 29, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve hereditary cancer panel genetic testing services. 
 
You asked the Plan to pre-approve hereditary cancer panel genetic testing services. You say that this testing is 
medically necessary. The Plan denied your request. The Plan says that the requested genetic testing services are 
not approved by the Food and Drug Administration (FDA). 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 hereditary cancer panel genetic testing 
services. Our reviewer says that the requested items/services are considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has a new diagnosis of Gleason 8 prostate 
cancer. Per the National Comprehensive Cancer Network guidelines, there is a high risk assessment for breast 
and ovary for individuals with high risk prostate cancer. The requested services are medically reasonable and 
necessary. In addition, the Plan has failed to provide any evidence that the requested testing is not FDA 
approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of hereditary cancer panel genetic testing services have been met. Therefore, we 
decided that the Plan has to pre-approve hereditary cancer panel genetic testing services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a color shroud (K0108) and electrical connection 
between power devices (E2311). 
 
You asked the Plan to pre-approve power wheelchair equipment. You say that you would like the denial for 
these items reconsidered. The Plan denied your request. The Plan says although most services have been 
approved, the criteria for coverage of this equipment have not been met. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.  The rules say that the electrical connection between power devices is subject to the criteria 
listed in the Medicare rules section. 
 
The color shroud item in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. 
 
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 for the electrical connection. Our reviewer says that the 
requested electrical connection is not medically reasonable and necessary. Our physician reviewer found that 
the member has a neurologic disorder with functional deficits. He meets criteria for the addition of multiple 
power options including power tilt and recline. The requested accessories are not medically necessary as he 
does have use of his hands and can operate and control the power options using the switches that are included 
in the basic wheelchair.  
 
Therefore, we decided that the Plan does not have to pre-approve a color shroud (K0108) and electrical 
connection between power devices (E2311).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and 
management of an established patient (99336) rendered by the out-of-network (OON) provider on August 24, 
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 domiciliary or rest home visit for the evaluation and management of an established 
patient (99336) rendered by the out-of-network (OON) provider on August 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stationary oxygen concentrator. 
 
You asked the Plan to pre-approve a stationary oxygen concentrator. You say that this device is medically 
necessary. The Plan denied your request. The Plan says the criteria for coverage of the requested oxygen 
concentrator have not been met. 
 
The Plan must follow Medicare rules. The rules say that for patients with arterial PO2 at or above 60 mm Hg or 
arterial O2 saturation at or above 90%, there is a rebuttable presumption of non-coverage for home oxygen.   
 
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 stationary oxygen concentrator. Our 
reviewer says that the requested stationary oxygen concentrator is not medically reasonable and necessary. Our 
physician reviewer found a stationary oxygen concentrator is considered not medically necessary because 
criteria are not met. This patient has chronic obstructive pulmonary disease (COPD) with documented 
hypoxemia during exercise breathing room air (SpO2 84%) and has been approved for portable oxygen. The 
room air SpO2 at rest is 90% or above, which does not meet requirements for oxygen supplementation at rest. 
Therefore the denial is upheld. However, many COPD patients with exertional hypoxemia also have sleep 
hypoxemia, so consideration should be given to checking sleep oximetry.  
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 stationary oxygen concentrator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a stationary oxygen concentrator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injections provided on July 9, 2021 by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the injections. You say that these services were referred by the enrollee's 
physician. The Plan denied your request. The Plan says the denial of payment for this service is correct, 
because this provider is out-of-network with the Plan and the ordering physician was also out-of-network with 
the Plan. 
 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 injections provided on July 9, 2021 by an out-
of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interim abutment (D6051) for tooth #12. 
 
You asked the Plan to pre-approve an interim abutment. You say that this service is necessary. The Plan denied 
your request. The Plan says this service is not covered by your dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
interim abutment (D6051) for tooth #12.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on June 28, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
We looked at the file and Medicare rules. The file does not contain documentation of an established 
relationship between the enrollee and the ordering provider. Without a record showing that this provider is 
treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on June 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite of one surface (D2330), resin-
based composite of four or more surfaces (D2335), and two applications of desensitizing resin (D9911 x2) 
provided on December 30, 2021. 
 
You asked the Plan to pay for the resin-based composites and applications of desensitizing resin. You say that 
these services denied for being non-covered charges, yet on November 10 the same procedures were covered. 
You also say that perhaps your provider coded these in error, but your 2022 plan material states these 
procedures are covered, and you wonder if these same codes did not apply in 2021. The Plan denied your 
request. The Plan says these services are not covered benefits under your dental plan. The claim for November 
10, 2021 did not include payment for any of the service billed for December 30, 2021.  
The Plan also says that it was confirmed that your dental coverage did change in 2022 and additional coverage 
was included, however, these services were rendered in 2021 and the claim was correctly processed using your 
2021 benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the resin-
based composite of one surface (D2330), resin-based composite of four or more surfaces (D2335), and two 
applications of desensitizing resin (D9911 x2) provided on December 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) testing provided on 
September 29, 2021. 
 
You asked the Plan to pay for the F1CDx testing. You say that this is an approved test for patients with 
advanced cancer and should be covered per the National Coverage Determination 90.2. The Plan denied your 
request. The Plan says the ordering provider listed on the claim was contacted. An office staff member 
indicated that the provider had not ordered any genetic testing in the time period prior to this date of service. As 
such, this testing cannot be paid because there was no ordering provider. 
 
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. In this case, only pathology records, a requisition form, and the 
results of this testing were submitted. No records from the ordering provider were submitted to allow 
confirmation that the Medicare coverage rules are met. Based on this information, we decided that there is 
insufficient information in the record to determine if Medicare rules for coverage of the FoundationOne CDx 
(F1CDx) testing provided on September 29, 2021. have been met. Therefore, we decided that the Plan does not 
have to pay for the FoundationOne CDx (F1CDx) testing provided on September 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 CDs diagnostic testing provided on August 
15, 2021. 
 
You asked the Plan to pay for the Guardant360 CDs diagnostic testing. You say that Medicare billing 
guidelines are being misinterpreted. You state that the POS code for lab testing only must match where the 
sample is taken for tests paid on the Physician Fee Schedule. You feel that POS code 81 is appropriate for this 
type of testing. The Plan denied your request. The Plan says the POS code for lab testing must match the 
location where the sample is 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 CDs diagnostic testing 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 CDs diagnostic testing provided 
on August 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the EKG provided on November 29, 2021. 
 
You asked the Plan to waive the copayment for the EKG. You say that the EKG was part of the normal intake 
process and should be covered by the specialist visit copay. The Plan denied your request. The Plan says the 
copayment applied is correct. 
 
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 Medicare-covered non-radiological diagnostic services.  
 
 
 You have been asked to pay $14.26 for the EKG, which is less than the $20 copayment for this service. The 
EKG 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 EKG provided on November 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sterile gloves provided on July 17, 2021. 
 
You asked the Plan to pay for the services provided. You say that the records indicate the services were an 
emergency. The Plan denied your request. The Plan says the code is not eligible for reimbursement. 
 
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 A4930 is gloves, sterile, per pair. We find that the 
payment for CPT code A4930 is packed into payment for other services. There is no separate payment for this 
service. Therefore, we decided that the Plan does not have to pay for the sterile gloves provided on July 17, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on November 23, 2021. 
 
You asked the Plan to waive the copayment for the CT scan. You say that the services should be covered as 
you disagree with the charges. 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 $150 
copayment for Inpatient stay: Covered services received in a hospital or SNF during a non-covered inpatient 
stay.  
 
 
  You have been asked to pay a $117.79 copayment for a CT scan, which is less than the standard $150. CT 
scans fall within the Inpatient stay: Covered services received in a hospital or SNF during a non-covered 
inpatient stay 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 computed tomography 
(CT) scan provided on November 23, 2021.