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

 
We decided that the Plan does not have to pay for the complete series x-ray (D0210) provided on March 2, 2022. 
 
You asked the Plan to pay for the dental service. You say that you had to change dentists. You also say that the 
new dentist required a new x-ray. The Plan denied your request. The Plan says the frequency limit has been 
exceeded. 
 
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 and complete series x-ray is listed as 
covered, there are frequency limits that apply. The record shows that the Plan paid for a complete series x-ray 
that you received on March 15, 2021, less than 60 months ago. Therefore, we decided that the Plan does not 
have to pay for the complete series x-ray (D0210) provided on March 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81220, 81225, 81227, 81230, 
81240, 81241, 81291, 81355, and 81479 provided on April 29, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not separately payable. 
 
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 codes 81220, 81225, 81227, 81230, 81240, 81241, 81291, 81355, and 81479 are not 
supported in the medical record. Specifically, if a laboratory assays two or more genes in an enrollee in 
parallel, those two or more genes will be considered part of the same panel. A panel constitutes a single 
procedural service, so one code must be submitted for the panel. Review of the file does not support that only 
one code was submitted for the panel provided. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay 
for the laboratory services coded 81220, 81225, 81227, 81230, 81240, 81241, 81291, 81355, and 81479 
provided on April 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on January 20, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this is not a covered benefit, as there is no evidence to support that the referring provider was 
treating the patient. 
 
Medicare rules say that a physician order must be present for labs to be covered. 
 
There is no real evidence to show that the referring provider for this test was actually treating the patient. Based 
on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, 
we decided that the Plan does not have to pay for laboratory services provided to the enrollee on January 20, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share amount for the porcelain crown (D2740) 
provided on March 8, 2022. 
 
You asked the Plan to waive the cost share amount for the dental service. You say that this type of crown was 
chosen based on medical necessity. The Plan denied your request. The Plan says the claim processed based on 
the alternate benefit. The Plan says that benefits have been paid based on the least costly method of treatment. 
The Plan also says the remaining balance is your responsibility. 
 
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 and crowns are listed as covered, the 
alternate benefit of a porcelain fused to predominantly base metal crown was applied. The record shows that 
the Plan paid the 50% coinsurance for the alternate benefit. The remaining amount is a contractual obligation 
you agreed to when you enrolled in the Plan's dental coverage. 
 Therefore, we decided that the Plan does not have to waive the cost share amount for the porcelain crown 
(D2740) provided on March 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on April 20, 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 the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on April 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on February 22, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that the ordering physician's office failed to obtain 
authorization for the denied service. The Plan denied your request. The Plan says this provider is not a network 
provider with the Plan. The Plan also says that they have also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for laboratory services provided on February 22, 
2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable gaseous oxygen system (E0431), an oxygen 
concentrator (E1390) and a portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve oxygen equipment. You say that you disagree with the denial and would 
like to request reconsideration. The Plan denied your request. The Plan says the enrollee has been on 
supplemental oxygen since February 2019. The enrollee has met the 36-month rental cap. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of oxygen equipment have not been met. Specifically, you have exhausted your 36-month rental cap 
for oxygen equipment. Please note, after 36 months, the vendor is required to provide contents and service for 
months 37-60. Therefore, we decided that the Plan does not have to pre-approve a portable gaseous oxygen 
system (E0431), an oxygen concentrator (E1390) and a portable oxygen concentrator (E1392).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the office visits with an ophthalmologist 
(92012, 99215, 99204) and ophthalmic ultrasounds (76512) provided from February 7, 2022, through March 1, 
2022, and the lens upgrades (V2781, V2782, V2750) provided on March 16, 2022. 
 
You asked the Plan to waive the copayments for the medical vision care and lens upgrades. You say that you 
feel you should not be responsible for uncovered charges or copayments related to the treatment which was 
necessary following your cataract surgery. The Plan denied your request. The Plan says these claims were 
processed correctly, and your share of the cost for these services have been assessed in accordance with your 
contract. The Plan also states they have opened a separate grievance case regarding your concerns. 
 
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 x-rays, a $40 copayment for Medicare covered exams to diagnose and treat 
diseases and conditions of the eye and a $40 copayment for Medicare-covered office visits with a specialist. 
The rules also say that Medicare does not cover progressive lenses (V2781), high index (V2782) lens upgrades, 
and anti-reflective coating (V2750) is only covered when medical necessity is documented, and the service is 
billed appropriately. 
 
You have been asked to pay a $40 copayment for each day that you visit an ophthalmologist and/or received a 
covered eye exam and a $35 copayment for the ophthalmic ultrasounds. 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. In addition, the lens upgrades (V2781, V2782) are not 
covered by Medicare, and no medical necessity was documented/claimed for the anti-reflective coating 
(V2750). Therefore, we decided that the Plan does not have to waive the copayments for the office visits with 
an ophthalmologist (92012, 99215, 99204) and ophthalmic ultrasounds (76512) provided from February 7, 
2022, through March 1, 2022, or pay for the lens upgrades (V2781, V2782, V2750) provided on March 16, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided from March 2, 2022, to 
March 16, 2022. 
 
You asked the Plan to pay for physical therapy services. You say that the patient mislead you by giving you 
information that she was covered under Medicare. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physical therapy services provided from March 2, 2022, to 
March 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ENT specialist visit provided on March 22, 
2022. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you should not have a 
copayment for this visit. The Plan denied your request. The Plan says the copayment applied was 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 $35 
copayment for Medicare-covered specialist visits.  
 
You have been asked to pay a $35 copayment for a specialist visit. A specialist visit falls within the 
Physician/Practitioner Services, Including Doctors Office Visits 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 ENT specialist visit provided on March 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the podiatry services provided on February 2, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the podiatry services. You say that you were unaware that the provider was 
OON. The Plan denied your request. The Plan says the rendering provider is an OON provider and there was 
no referral from an in-network provider or an approved authorization. Also, the service rendered was 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 the podiatry services provided on February 2, 
2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM), 
supplies and receiver (K0553, K0554). 
 
You asked the Plan to pre-approve a Dexcom G6 CGM, supplies and receiver. You say that the services should 
be covered because the enrollees fingers are bruised and results in her not checking her blood glucose. The 
Plan denied your request. The Plan says the enrollee does not meet prior authorization criteria. 
 
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 use insulin 
with at least three daily injections and 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 a Dexcom 
G6 CGM, supplies and receiver have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Dexcom G6 continuous glucose monitor (CGM), supplies and receiver (K0553, K0554).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on September 28, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that a referral is not required. The Plan denied your 
request. The Plan says the services were provided out-of-network and were not approved in advance. 
 
 
 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 on September 28, 2021, 
by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the duplex scan of extremity veins (93970) provided on 
November 23, 2021. 
 
You asked the Plan to pay for the duplex scan. You say that this claim was billed appropriately. The Plan 
denied your request. The Plan says the Place of Service (POS) code submitted on this claim is incorrect. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that the Place of Service (POS) code is generally used to reflect the actual setting where the services 
were received by the beneficiary. However, there are exceptions. When a service is rendered to a patient who is registered inpatient in a hospital, the correct POS code, regardless of where the face-to-face service occurs, is 
that of the appropriate inpatient POS code (at a minimum POS code 21). 
 
We find that CPT code 93970 is not supported as billed. Specifically, this claim was billed with POS code 22 
(On Campus  Outpatient Hospital). However, the documentation shows that the enrollee was inpatient status 
from November 19, 2021, to November 25, 2021. That means that an inpatient POS code must be used on this 
claim. Based on this information, we decided that Medicare rules for coverage of the duplex scan have not been 
met. Therefore, we decided that the Plan does not have to pay for the duplex scan of extremity veins (93970) 
provided on November 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Freestyle Libre continuous glucose monitor (CGM) sensors 
(K0553) provided on December 25, 2021. 
 
You asked the Plan to pay for Freestyle Libre CGM sensors. You say that the items at issue were 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 enrollee's 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 items at issue. The record shows that 
the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided 
that the Plan does not have to pay for Freestyle Libre continuous glucose monitor (CGM) sensors (K0553) 
provided on December 25, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that the requested Keytruda is medically necessary. The 
Plan denied your request. The Plan says the requested Keytruda is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Keytruda. Our reviewer says that the 
requested Keytruda is not medically necessary. Our physician reviewer found the requested use of Keytruda is 
not FDA-approved for the enrollees diagnosis. FDA approval is for treatment (as a single agent) of advanced 
endometrial carcinoma that is MSI-H or dMMR (as determined by an approved test) in patients with disease 
progression following prior systemic therapy (in any setting) and are not candidates for curative surgery or 
radiation. She has not received any prior systemic treatment or treatment of unresectable or metastatic MSI-H 
or dMMR solid tumors (as determined by an approved test) in adult and pediatric patients that have progressed 
following prior treatment and have no satisfactory alternate treatment options.  The use of Keytruda in the enrollee's case is not supported by one of the major drug compendia or by clinical 
research that appears in a CMS-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed on November 7, 2021. 
 
You asked the Plan to pay for procedure code 99053. You say that this claim is for an emergency physician and 
the date of service is compatible with the code billed. You say that the attached medical records should be 
reviewed, and payment made on the claim. The Plan denied your request. The Plan says CPT code 99291 is 
approved, and CPT code 99053 remains denied as bundled services are not separately payable. 
 
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 99053 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99053 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99053 billed on November 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgery services provided on January 20, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the surgery services. You say that you have provided the medical records to 
appeal the denied service. The Plan denied your request. The Plan says the rendering provider is an OON 
provider and there was no referral from an in-network provider or an approved authorization. Also, the service 
rendered was 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 the surgery services provided on January 20, 2022, 
by an out-of-network (OON) provider.