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

 
We decided that the Plan does not have to pay for the drug testing services provided on July 2, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.  
 
We looked at the file and Medicare rules. The documentation shows that the services in question were billed 
with POS code 81. However, the records indicate that the specimen was collected in an office setting, which 
would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. 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 the drug testing services provided on July 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from June 7, 2021, 
through June 9, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient admission was medically 
necessary. The Plan denied your request. The Plan says the inpatient admission was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the record did not show that at the time of inpatient admission the admitting 
physician reasonably expected that the patient's necessary hospital care (including earlier emergency 
department and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from June 7, 2021, through  
June 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on November 9, 2021.
You asked the Plan to pay for the dental service. You say that this was not just a visit for a check up. You say that you had a severe toothache. You say that you were unable to chew on this tooth or near that area. You also say that this should be covered. The Plan denied your request. The Plan says 1 limited oral evaluation is covered per plan year. The Plan also says that 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 limited oral evaluation is covered, the frequency limit of once per plan year has been exceeded. The record shows that the Plan paid for a limited oral evaluation that you received on January 25, 2021. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on November 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for prophylaxis (D1110) provided by a participating provider on
October 12, 2021.
You asked the Plan to pay for prophylaxis. You say that you did not know that your supplemental benefits were
cancelled. You say that you would have not had this done if you had known that. The Plan denied your request.
The Plan says the benefit limit for D1110 has already been met and exhausted.
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. The Plan covers prophylaxis
two times per year.
We looked at the file and Medicare rules. Evidence was provided to show that D1110 was provided on January
6, 2021, and on April 6, 2021. Based on this information, we decided that the Plan's rules for coverage of
prophylaxis have not been met. Therefore, we decided that the Plan does not have to pay for prophylaxis
(D1110) provided by a participating provider on October 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve epidural steroid injections (64484, 64483).
You asked the Plan to pre-approve the epidural steroid injections. You say that the injections are medically
necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that Epidural Steroid Injections are covered for pain
lasting 4 weeks or more with failure or inability to tolerate non-invasive conservative care consisting of a an
appropriate combination of medication (e.g. Tylenol, pain medications) in addition to physical therapy, spinal
manipulation therapy, home exercise program or other interventions based on the individual's specific history,
physical findings and imaging results.
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 epidural steroid injections. Our
reviewer says that the injections are not medically necessary. Our physician reviewer found there has been no
documented trial of non-invasive or conservative care consisting of an appropriate combination of medication
in addition to physical therapy, spinal manipulation therapy, a home exercise program, or other interventions.
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 epidural steroid injections have not been met. Therefore, we decided that the
Plan does not have to pre-approve epidural steroid injections (64484, 64483).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a vaccine provided on September 16, 2021, by an out-of-network
(OON) provider.
You asked the Plan to pay for a vaccine. You say that you did not know the provider was an out-of-network
provider and would like for this service to be paid. The Plan denied your request. The Plan says the rendering
provider is an out-of-network provider and there was no prior approved 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 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 vaccine provided on September 16, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on May 24, 2021.
You asked the Plan to pay for the Guardant360 testing. You say that you feel that the correct POS for this claim is 81. The Plan denied your request. The Plan says the POS code reported does not match the location in which the sample was taken.
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. The documentation does not indicate this sample was taken by the lab directly. As such, the use of POS code 81 is not supported. Based on this information, we decided that Medicare rules for coverage of the Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on May 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital outpatient clinic visit (G0463), laboratory services 
(87070, 87075, 89051, 89060, 87205), arthrocentesis injections of the major joint or bursa; without ultrasound 
guidance (20610), an injection; single tendon sheath, or ligament (20550), a betamethasone acetate 3 mg and betamethasone sodium phosphate 3 mg injection (J0702), and an x-ray examination of the knee (73564) 
provided on January 14, 2021 to August 3, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a hospital outpatient clinic visit, laboratory services, arthrocentesis injections of 
the major joint or bursa; without ultrasound guidance, an injection; single tendon sheath, or ligament, a 
betamethasone acetate 3 mg and betamethasone sodium phosphate 3 mg injection, and an x-ray examination of 
the knee. You say that you were under the impression that all of your claims should get paid because you have 
Medicare and Medicaid coverage. The Plan denied your request. The Plan says there is no basis for out-of-
network care as the care this member received could have been performed safely by an in-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a hospital outpatient clinic visit (G0463), 
laboratory services (87070, 87075, 89051, 89060, 87205), arthrocentesis injections of the major joint or bursa; 
without ultrasound guidance (20610), an injection; single tendon sheath, or ligament (20550), a betamethasone 
acetate 3 mg and betamethasone sodium phosphate 3 mg injection (J0702), and an x-ray examination of the 
knee (73564) provided on January 14, 2021 to August 3, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81479, 81286, 81403, 81404, 81405, 81406, 81407, 81408) provided September 9, 2021.
You asked the Plan to pay for the genetic testing. You say that this testing was medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that Next Generation Sequencing (NGS) is indicated for inherited types of cancers such as breast or ovarian, or acquired cancers that are recurrent, relapsed, refractory, metastatic, or advanced stage III or IV when results are used to decide cancer treatment. We looked at the file and Medicare rules. No clinical records were provided showing a cancer diagnosis. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (81479, 81286, 81403, 81404, 81405, 81406, 81407, 81408) provided September 9, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (procedure codes 85384 and 85379) provided to the enrollee on April 7, 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 these are duplicate services to the same service billed by another provider for the same date of service.
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 85384 and 95379 are not supported in the medical record. Specifically, the case file shows that these codes were already paid on the same date of service. 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 (procedure codes 85384 and 85379) provided to the enrollee on April 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial observation care (99220) provided on October 24, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for initial observation care. You say that this patient was observation with place of 
service 22, and there is no authorization referral needed when seen under place of service 22. The Plan denied 
your request. The Plan says this provider is not a network provider with the Plan and 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 initial observation care (99220) provided on 
October 24, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office services provided on October 28, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office services. You say that you did not realize an authorization was needed. 
The Plan denied your request. The Plan says the rendering provider is an out-of-network provider and there 
was no referral from an in-network provider or an approved authorization. Also, services rendered was not 
urgent or emergent in nature. 
 
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 office services provided on October 28, 2021, 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 coronavirus (COVID) test provided on October 15, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for a COVID test. You say that you needed to get the test done to travel back to the United States so it should be an emergency. The Plan denied your request. The Plan says the enrollee opted and paid for a non-urgent, non-medically needed COVID screening to return home. 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 a coronavirus (COVID) test provided on October 15, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cardura (doxazosin) 1mg tablets. 
 
You asked the Plan to pre-approve the Cardura tablets. You say that the enrollee's blood pressure is 
uncontrolled, and this medication is needed to assist in lowering it. The Plan denied your request. The Plan says 
this oral drug is not covered by Medicare Part B. 
 
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 requested here are not among the types which are covered by Medicare Part B. 
Therefore, we decided that the Plan does not have to pre-approve Cardura (doxazosin) 1mg tablets.  
 
Benefits for the Cardura tablets 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99212) provided on November 11, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you were not aware that your practice is out-of-
network with the Plan. The Plan denied your request. The Plan says the rendering provider is a non-
participating provider and there is no referring provider involved in these services. The Plan also says that they 
did not authorize any services for this provider. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit (99212) provided on November 11, 
2021, 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 special push wheelchair to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve a special push wheelchair. You say that the requested provider you have used in the past and did not know when you switched to the Plan the provider would be out-of-network. You also say that the list of in-network providers that was given to you do not carry the proper equipment. The Plan denied your request. The Plan says the provider is an out-of-network provider. An in-network provider was given to the enrollee in which it was confirmed that they carry the equipment that is needed for the enrollee.
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 a special push wheelchair to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services provided on October 7, 2021, by
an out-of-network (OON) provider.
You asked the Plan to pay for the outpatient hospital services. You say that no authorization is needed, and the
service provided to the enrollee was medically necessary. The Plan denied your request. The Plan says the
rendering provider is an out-of-network provider and there was no referral from an in-network provider or an
approved authorization. Also, the services 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 outpatient hospital services provided on October 7, 2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound (76707) provided on October 28, 2021.
You asked the Plan to waive the copayment for the ultrasound. You say that the services should be covered as you were referred. 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 $105 copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.
You have been asked to pay a $105 copayment for an ultrasound. Ultrasounds 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 an ultrasound (76707) provided on October 28, 2021.