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

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on July 2, 
2021. 
 
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 the denied codes remains not supported. 
 
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 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 drug testing services provided to the enrollee on July 2, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided 
from October 24, 2021, to October 26, 2021. 
You asked the Plan to waive the copayment for an ER visit. You say that the request for an inpatient hospital 
stay was denied. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. 
 
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 in-network emergency room services.  
 
The record shows this claim for an ER visit was approved, and you have a cost sharing amount. You have been 
asked to pay a $50 copayment for an ER visit. An ER visit falls within the Emergency Care 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 emergency room (ER) visit provided from October 24, 
2021, to October 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the prostate artery embolization and related services.

You asked the Plan to pre-approve the prostate artery embolization and related services. You say that there are studies that prove effectiveness, and this is also formally approved by the FDA. You say that your doctor told you that this has been covered for other patients before. The Plan denied your request. The Plan says guidelines say this procedure is not yet proven to work better and the denial is correct.
 
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 prostate artery embolization and related services. Our reviewer says that the member does not meet the NCD coverage criteria. Our physician reviewer found that prostatic arterial embolization is considered an experimental technique. Very limited studies have demonstrated possible short-term safety and efficacy. The most recent guidelines do not recommend this procedure outside of a clinical trial 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 the prostate artery embolization and related services have not been met. Therefore, we decided that the Plan does not have to pre-approve the prostate artery embolization and related services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 2 heavy duty multiple power option wheelchair.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is no medical necessity for this request.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 wheelchair is not medically reasonable or necessary. Our physician reviewer found the records do not support that the enrollee is at high risk for skin breakdown. There is no requirement for bladder catheterization. There is no evidence of spasticity in order to meet criteria for the power tilt and recline; thus, the multiple power options are not medically reasonable or necessary. Based on the medical records provided, the patient appears to meet criteria for a group 2 power wheelchair with no power option. 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 a group 2 heavy duty multiple power option wheelchair.
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 the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 based on the medical records provided there is 
no documentation that the enrollee requires the services on an inpatient basis, only in a skilled nursing facility 
setting. Services in a long-term care facility on a part time basis appear appropriate 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you have pain, flat feet with spurs, and swelling 
of the heel that deforms your ankle and foot. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you consider the items medically 
necessary. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on September 
20, 2021. 
 
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 claim does not meet coding standards. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
laboratory services provided to the enrollee on September 20, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the physical therapy provided on October 
1, 2021, and October 4, 2021. 
 
You asked the Plan to waive the copayment for the physical therapy. You say that the denial of payment is not 
appropriate and should be removed. The Plan denied your request. The Plan says the cost sharing 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 $30 
copayment for Medicare-covered physical therapy visits.  
 
 
 You have been asked to pay a $60 copayment ($30 x 2 visits) for the physical therapy. The physical therapy 
falls within the Outpatient Rehabilitation Services 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 physical therapy provided on October 1, 2021, and October 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan (70450) 
provided on December 2, 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 and never asked for the services. 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 $130 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 You have been asked to pay a $99.60 copayment for a CT scan, which is less than the standard $130. 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 computed tomography (CT) scan (70450) provided on December 2, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray and laboratory services provided 
on August 23, 2021, and September 3, 2021. 
 
You asked the Plan to waive the copayment for the x-ray and laboratory services. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $100 copayment and a $40 copayment for Outpatient hospital services.  
 
 
  The enrollee has been asked to pay a $29.43 copayment the x-ray, which is less than the standard $100 and a 
$40 copayment for laboratory services. This means that the enrollee has been asked to pay the correct amount 
based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay 
upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an x-
ray and laboratory services provided on August 23, 2021, and September 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prostate cancer screening (G0103) provided on August 
25, 2021 
 
You asked the Plan to pay for code G0103. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says you exhausted the benefit limit. The Plan follows Medicare rules. Medicare rules say that PSA screening is covered once every 12 months. 
 
We looked at the file and Medicare rules. The file shows that you received a PSA screening on May 19, 2021, 
that the Plan covered. The screening on August 25, 2021, was performed less than 12 months from your 
previously covered exam. Therefore, we decided that the Plan does not have to pay for the prostate cancer 
screening (G0103) provided on August 25, 2021
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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational 
therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable 
expectation that this you will be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an IRF. 
 
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: Lab
Decision: Favorable

 
We decided that the Plan has to waive the copayment for blood services (85025) provided on September 15, 
2021. 
 
You asked the Plan to waive the copayment for the blood services. You say that the services should be covered 
as you disagree with the charges and your contract with the plan states there's a $0 copayment. The Plan denied 
your request. The Plan says that 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. Your 
contract with the Plan says that enrollees must pay a $0 copayment for Outpatient diagnostic tests and 
therapeutic services and supplies, specifically blood services.  
 
The Plan says you must pay a $6.99 copayment for the blood services. Based on the Plan contract, however, 
you cannot be asked to pay more than a $0 copayment for blood services. Therefore, we decided that the Plan 
has to waive the copayment for blood services (85025) provided on September 15, 2021.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified preventative procedure (D1999) provided by 
a participating provider on November 5, 2021. 
 
You asked the Plan to pay for an unspecified preventative procedure. You say that you were told that these 
services would be covered. The Plan denied your request. The Plan says D1999 is not a covered 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 pay for an 
unspecified preventative procedure (D1999) provided by a participating provider on November 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete 
series of intraoral x-rays (D0210) provided on November 17, 2021. 
 
You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. You 
say that you were unaware that these services would not be covered due to having been misinformed by the 
dental provider. The Plan denied your request. The Plan says these services exceed the maximum counts 
allowed per period. 
 
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, comprehensive oral evaluation 
(D0150) and complete series of intraoral x-rays (D0210) are each limited to one procedure every three plan 
years. The record shows that you received a comprehensive oral evaluation (D0150) and complete series of 
intraoral x-rays (D0210) on July 28, 2020 and your comprehensive oral evaluation (D0150) and complete 
series of intraoral x-rays (D0210) benefits have been exhausted. Therefore, we decided that the Plan does not 
have to pay for the comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) 
provided on November 17, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hot or cold packs therapy (97010) provided on December 9, 2021. 
 
You asked the Plan to pay for hot or cold packs therapy. You say that these services were necessary and were 
pre-approved. The Plan denied your request. The Plan says they have agreed to pay for the therapy services 
described with codes 97530, 97112, 97110, and 97140. However, code 97010 has a status code of "b" which 
means that payment for this service is always bundled into the payment for another service. This means that 
97010 is not eligible for separate payment and remains denied. 
 
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 97010 has a status code of B - Bundled Code. Payment for covered services is 
always bundled into payment for other services not specified. If Relative Value Units (RVUs) are shown, they 
are not used for Medicare payment. If these services are covered, payment for them is subsumed by the 
payment for the services to which they are incident. 
 
We find that CPT code 97010 is not supported in the medical record. Specifically, payment for this service is 
always bundled into payment for another service. Based on this information, we decided that Medicare rules 
for coverage of hot or cold packs therapy have not been met. Therefore, we decided that the Plan does not have 
to pay for hot or cold packs therapy (97010) provided on December 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation (D9310) and preventive procedure (D1999) 
provided on November 18, 2021, and December 1, 2021. 
 
You asked the Plan to pay for the consultation and preventive procedure. You say that you had an infected 
tooth and were referred to an oral surgeon. You also say that you believed surgery with bone removal would be 
covered. The Plan denied your request. The Plan says these services are not covered expenses under your 
dental plan. 
 
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 
consultation (D9310) and preventive procedure (D1999) provided on November 18, 2021, and December 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three crowns (D2740 x3), three core buildups, including 
any pins when required (D2950 x3), and a pontic (D6242). 
 
You asked the Plan to pre-approve the crowns, core buildups, and pontics. The Plan denied your request. The 
Plan says the records must include pre-treatment x-rays to support the need for these services. The Plan also 
says that supporting documents were not submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 three crowns (D2740 x3), three core 
buildups, including any pins when required (D2950 x3), and a pontic (D6242). have been met. The provider did 
not submit any narrative or x-ray information to support the medical necessity of the requested services. 
Without any information, there is no way to know if these procedures are necessary. Therefore, we decided that 
the Plan does not have to pre-approve three crowns (D2740 x3), three core buildups, including any pins when 
required (D2950 x3), and a pontic (D6242).