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

 
We decided that the Plan does not have to pay for lab services (88305) provided on April 12, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported in 
the medical record. 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, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (88305) provided on April 12, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) 
provided April 1, 2022. 
 
You asked the Plan to pay for the ambulance response. You say that the doctor's office felt it was necessary to 
call the ambulance. The Plan denied your request. The Plan says this service is not covered when there is no 
transport. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 The ambulance company did not provide transport services on April 1, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport (A0998) provided April 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bilateral L4-L5 medial branch block injection 
provided to the enrollee on May 20, 2022. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is not anything unique about the enrollee's medical condition to warrant a 
deviation from Medicare policy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the enrollee has back pain and left buttock pain with radicular symptoms to the left 
lower extremity/left thigh. The enrollee's magnetic resonance imaging (MRI) showed L4-L5 spinal stenosis. 
The review has determined that it has been at least three months of moderate to severe pain that has not 
responded to conservative care and the facet joint is not the main source of pain. The review has determined 
that the enrollee does not meet the coverage criteria detailed in the LCD. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a bilateral L4-L5 medial branch block injection provided to the enrollee on May 20, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99309) 
rendered by the out-of-network (OON) provider on March 8, 2022. 
 
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 subsequent nursing facility care, per day (99309) rendered by the out-of-network 
(OON) provider on March 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 10, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. 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 authorization is 
required prior to an out-of-network visit. 
 
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 an office visit provided on June 10, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services provided on June 14, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for ophthalmological services. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-of-
network, and it was determined these services can be received in-network. 
 
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 ophthalmological services provided on June 14, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility care visit provided on April 23, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for a nursing facility care visit. You say that you treated the member without 
knowing the hospital staff did not obtain an authorization prior to treatment. The Plan denied your request. The 
Plan says an authorization was required prior to treatment from out-of-network physician. 
 
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 nursing facility care visit provided on April 23, 
2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the water circulating heat pad with pump (E0217) provided 
February 23, 2022 to March 14, 2022. 
 
You asked the Plan to pay for the water circulating heat pad with pump. You say that these services should be 
considered due to the enrollee's past medical history. The Plan denied your request. The Plan says this item is 
not covered by Medicare. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage 
of Water circulating heat pad with pump have not been met. Therefore, we decided that the Plan does not have 
to pay for the water circulating heat pad with pump (E0217) provided February 23, 2022 to March 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic services. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says Medicare policy specifically states the symptoms must bear a direct relationship to the 
level of subluxation for both imaging and clinical diagnosis of subluxation. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the case file does not contain documentation of a subluxation that has resulted in a neuromuscular 
condition. The requested treatments do not provide a significant and reasonable expectation of recovery or 
improvement of function. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve chiropractic services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the vertebral axial decompression, per 
session (S9090) provided from April 11, 2022, through May 9, 2022. 
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these services are 
not covered by the Plan or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to issue reimbursement for the vertebral axial decompression, per session (S9090) 
provided from April 11, 2022, through May 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for progressive lenses (V2781) provided on June 3, 2022. 
 
You asked the Plan to pay for progressive lenses (V2781). You say that under your EOC you have a $300 
combined allowance for eyeglasses and contact lenses every 24 months. You also say that you have not used 
any of that $300 benefit, thus the service provided on June 3, 2022, is covered under the EOC. The Plan denied 
your request. The Plan says the records indicate the maximum benefit for this service has been exhausted.  
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers $300 combined allowance for eyeglasses and contact lenses every 24 months. 
 
We looked at the file and the Plan's rules. The rules say that there is a $300 combined allowance for eyeglasses 
and contact lenses every 24 months. The record shows that the Plan paid $170 for a bifocal sphere (V2220) on 
June 3, 2022. The Plan also paid $130 toward the antireflective coating per lens (V2750), thus totaling $300 
($170 + $130 = $300). This means that you are responsible for $229 for the progressive lens (V2781) also 
received on June 3, 2022.  Based on this information, we decided that the Plan's rules for coverage of 
progressive lenses (V2781) have not been met. Therefore, we decided that the Plan does not have to pay for 
progressive lenses (V2781) provided on June 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided on September 18, 2018. 
 
You asked the Plan to pay for genetic testing. You say that this should be covered. The Plan denied your 
request. The Plan says this must be billed to the enrollee's primary insurance. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer.  
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has instructed 
you to bill the primary insurer. As the secondary insurer, the Plan cannot be held responsible for genetic testing 
until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not 
have to pay for genetic testing provided on September 18, 2018.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (87532, 87798) provided on April 28, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan 
denied your request. The Plan says documentation does not support the billed services. 
 
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 genetic testing (87532, 87798) provided on April 28, 2022. have been met. No clinical records were provided to support the services. Records 
were limited to lab results only. Therefore, we decided that the Plan does not have to pay for genetic testing 
(87532, 87798) provided on April 28, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs (A9270) provided from June 10, 
2022, through June 13, 2022. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says these items are not covered under your contractual 
policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs provided are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
(A9270) provided from June 10, 2022, through June 13, 2022.  Benefits for these items 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 the ambulance response and treatment, no transport (A0998) 
provided March 11, 2022. 
 
You asked the Plan to pay for the ambulance response. You say that the cost of this service is a hardship. The 
Plan denied your request. The Plan says this service is not covered when there is no transport. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 The ambulance company did not provide transport services on March 11, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport (A0998) provided March 11, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an NETest (86316). 
 
You asked the Plan to pre-approve an NETest. You say that you need this lab work to assess a tumor. The Plan 
denied your request. The Plan says this testing is not covered under Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that publications reviewed for NETest suggest it has 
potential but needs more independent studies and validation before it can be recommended. 
 
We looked at the file and Medicare rules. The requested test is not covered by Medicare. Therefore, we decided 
that the Plan does not have to pre-approve an NETest (86316).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided from February 26, 2021, to 
June 25, 2021. 
 
You asked the Plan to pay for the chiropractic services. You say that chiropractic care is unlimited and paid by 
the Plan. The Plan denied your request. The Plan says you have exceeded the benefit limit. 
 
The Plan covers a routine chiropractic services benefit. The Plan benefit says this benefit covers 12 routine 
chiropractic visits every year. 
 
We looked at the file and the Plans rules. The file shows you have exceeded the benefit limit of 12 routine 
chiropractic visits every year. Therefore, we decided that the Plan does not have to pay for chiropractic services 
provided from February 26, 2021, to June 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shingles vaccine provided on June 6, 2022. 
 
You asked the Plan to pay for the shingles vaccine. You say that you got one at a pharmacy and asked for a 
second one at the clinic because you knew it was covered. The Plan denied your request. The Plan says this is 
not covered by your Medicare Part B benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. 
The Plan follows the same rules.  
 
The Plan contract says that per Medicare rules, some vaccines such as those for shingles, Tdap, and foreign 
travel are Part D drugs and do not meet Medicare Part B coverage rules, and therefore, are not covered under 
your medical benefit. Therefore, we decided that the Plan does not have to pay for the shingles vaccine 
provided on June 6, 2022.  
 
Benefits for the shingles vaccine 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the physical therapy visits to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the physical therapy visits. You say that the OON providers location is 
easier to access. The Plan denied your request. The Plan says the requested provider is an OON provider and 
there are multiple in-network providers that are available and within the enrollee's service area. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the physical therapy visits to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and laboratory service provided on June 22, 
2022, by an OON provider. 
 
You asked the Plan to pay for an office visit and laboratory service. You say that you are appealing the claim 
payment denial for services rendered to our member on this date of service. The Plan denied your request. The 
Plan says the out-of-network services were not authorized. 
 
 
 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 an office visit and laboratory service provided on 
June 22, 2022, by an OON provider.