Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on August 5, 2020. 
 
You asked the Plan to pay for the services provided. You say that the claim was submitted 2 weeks prior to the 
allowed filing period. The Plan denied your request. The Plan says the claim was received past the allowed 
timeframe. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services provided was not filed until August 6, 2021. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the physician services provided on August 5, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a pharmacogenetic panel (81225, 81227, 81226, 81223, 
81241, 81328, 81335, 81400, 81401, 81230, 81231, 81240, 81232, 81406, 81350, 81479, 81291, 81306) 
provided on June 16, 2021. 
 
You asked the Plan to pay for a pharmacogenetic panel. You say that this is supported in the records. The Plan 
denied your request. The Plan says this was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
If a laboratory assays 2 or more genes in a patient in parallel, then those 2 or more genes will be considered 
part of the same panel. A panel constitutes a single procedural service, so 1 code must be submitted for the 
panel. 
 
We find that CPT codes 81225, 81227, 81226, 81223, 81241, 81328, 81335, 81400, 81401, 81230, 81231, 
81240, 81232, 81406, 81350, 81479, 81291, and 81306 are not supported in the medical record. Specifically, 
these codes were used to report a panel, which should be billed with one code. Based on this information, we 
decided that Medicare rules for coverage of a pharmacogenetic panel have not been met. Therefore, we decided 
that the Plan does not have to pay for a pharmacogenetic panel (81225, 81227, 81226, 81223, 81241, 81328, 
81335, 81400, 81401, 81230, 81231, 81240, 81232, 81406, 81350, 81479, 81291, 81306) provided on June 16, 
2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing services provided on May 20, 
2021. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the records do 
not support the billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code G0483 is definitive drug testing of 22 or more drug 
classes. We find that CPT code G0483 is not supported in the medical record. The records do not show that the 
testing of 22 or more drug classes was ordered due to patient history, clinical assessment, including medication 
side effects or inefficacy, suspicious behaviors, self-escalation of dose, doctor-shopping, indications/symptoms 
of illegal drug use, evidence of diversion, or other clinician documented change in affect or behavioral pattern. 
Based on this information, we decided that Medicare rules for coverage of the testing services have not been 
met. Therefore, we decided that the Plan does not have to pay for the definitive drug testing services provided 
on May 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for determination of refractive state (92015) provided June 16, 
2021. 
 
You asked the Plan to pay for the vision services. You say that you had called and verified that this clinic was a 
vision provider. You wanted to get a regular eye exam, and this has always been a $35 copay. The Plan denied 
your request. The Plan says eye refraction is only covered when rendered as part of a routine eye exam. 
 
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 these services when provided as part of a routine eye exam. The records show that 
this was a medical eye exam therefore, the refraction service is not covered. 
 
We looked at the file and the Plan's rules. The plan covers eye refraction when provided as part of a routine eye 
exam. Based on this information, we decided that the Plan's rules for coverage of the vision services have not 
been met. Therefore, we decided that the Plan does not have to pay for determination of refractive state (92015) 
provided June 16, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on June 17, 2021. 
 
You asked the Plan to pay for physical therapy services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require 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 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 on June 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more toward the dental services provided on March 31, 2021 
and July 14, 2021. 
 
You asked the Plan to pay more toward the dental services. You say that you took the dentist's advice and had 
the work done paying an additional $721 but immediately had pain while chewing. You say that the dentist saw 
an opportunity to bill the Plan for work that wasn't necessary, and the financial loss should be remedied. The 
Plan denied your request. The Plan says the annual limit allowed for this benefit year has been paid. 
 
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, you also have maximum benefit of 
$1,300 toward covered dental services every plan year. The Plan paid $1,300 toward the dental services 
provided on February 25, 2021 and March 31, 2021, which exhausted your benefit. Therefore, we decided that 
the Plan does not have to pay more toward the dental services provided on March 31, 2021 and July 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the lenses provided on July 20, 2021. 
 
You asked the Plan to pay more for the lenses. You say that the denial for the lenses is confusing. The Plan 
denied your request. The Plan says your benefit maximum has been exceeded. 
  
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 up to $200 every calendar year for eyeglasses, frames, lenses or contact lenses from 
participating network providers. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the lenses have not been met. Specifically, the Plan paid the maximum amount of $200 toward the 
lenses. Therefore, we decided that the Plan does not have to pay more for the lenses provided on July 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing amount for the inpatient hospital care 
provided from February 21, 2021, to February 28, 2021. 
 
You asked the Plan to waive the cost sharing amount for the inpatient hospital care. You say that you were 
advised that you have 1 to 2 years to live. You say that you went in for surgery 2 days later. You also say that 
you are on Social Security. The Plan denied your request. The Plan says the claim was processed correctly. 
 
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 $225 
copayment per day, days 1 to 7 for inpatient hospital care.  
You have been asked to pay $225 copayment per day, days 1 to 7 for the inpatient hospital care. The inpatient 
hospital care falls within the inpatient hospital care benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. $225 x 7 days = $1,575. 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 cost sharing amount for the inpatient hospital care provided from February 21, 
2021, to February 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on September 21, 2020. 
 
You asked the Plan to pay for the lab 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 do not show that the specimen was collected in a laboratory setting. 
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 lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on September 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on June 16, 2021 by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for drug testing. You say that you are appealing with supporting documentation. The 
Plan denied your request. The Plan says the denial of payment for this testing is correct, because this provider 
is out-of-network with the Plan and the ordering provider is also out-of-network with the Plan. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for drug testing provided on June 16, 2021 by an out-
of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for magnetic resonance angiography of the head (70544) 
provided on June 29, 2021. 
 
You asked the Plan to pay for magnetic resonance angiography services. You say that you would like this claim 
reprocessed for medical necessity. The Plan denied your request. The Plan says this claim was not billed with 
an appropriate modifier. 
 
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, we have confirmed that code 70544 
is a column II code to column I code 70551. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for magnetic resonance angiography of the head (70544) provided 
on June 29, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428-HR) 
provided on October 8, 2020. 
 
You asked the Plan to pay for the transportation service. You say that the service should be covered. The Plan 
denied your request. The Plan says ambulance transport to or from an outpatient office or facility is not a 
Medicare covered benefit. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the transportation service have not been met. Specifically, ambulance transport to or from an 
outpatient office or facility is not a Medicare covered benefit. Therefore, we decided that the Plan does not 
have to pay for the non-emergency ambulance transportation (A0428-HR) provided on October 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (0037U) provided on March 14, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that this was medically necessary. The Plan denied 
your request. The Plan says this was 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 laboratory services (0037U) provided on March 
14, 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 pharmacogenetic testing provided on March 31, 2021. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says only a single 
code should be reported for the procedure. 
 
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 looked at the file and the rules. If a single procedure is performed, only one HCPCS/CPT code with one 
unit of service may be reported for the procedure. Based on this information, we decided that Medicare rules 
for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay 
for the pharmacogenetic testing provided on March 31, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the neuroplasty procedure you had at an 
outpatient hospital facility on June 2, 2021. 
 
You asked the Plan to waive the copayment for the outpatient surgery. You say that this copayment is too high 
and you cannot afford it. The Plan denied your request. The Plan says you were charged this copayment 
correctly. 
 
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 $290 
copayment for surgery in an outpatient hospital facility.  
 
You have been asked to pay a $290 copayment for the outpatient surgery. 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 neuroplasty procedure you had at an outpatient hospital facility on June 2, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria.  
The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has primary osteoarthritis 
of the left knee. She has not tried and failed the Plan's required drugs, Orthovisc and Monovisc. The records do 
not show that the required drugs would be contraindicated or less effectie; therefore, Euflexxa is not reasonable 
or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Euflexxa
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for thoracentesis and catheter drainage on 
March 16, 2021, and April 16, 2021. 
 
You asked the Plan to waive the copayments for thoracentesis and catheter drainage. You say that you were not 
informed that you would owe such a high copayment and cannot afford the charges. The Plan denied your 
request. The Plan says the claims were processed correctly and you are being charged the correct 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 $350 
copayment for outpatient surgery, including services provided at hospital outpatient facilities. 
 
 
You received thoracentesis at an outpatient hospital facility on March 16, 2021. Thoracentesis is considered an 
outpatient surgical procedure. Therefore, you are responsible to pay the $350 copayment.  
 
You received catheter drainage at an outpatient hospital facility on April 16, 2021. Catheter drainage is 
considered an outpatient surgical procedure. Therefore, you are responsible to pay the $350 copayment.  
 
The total amount you owe is: $700.   
 
You have been asked to pay the total copayment amount of $700 for thoracentesis and catheter drainage. 
Thoracentesis and catheter drainage fall within the outpatient surgery, including services provided at hospital 
outpatient facilities and ambulatory surgical centers 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 
copayments for thoracentesis and catheter drainage on March 16, 2021, and April 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided on 
December 14, 2020. 
 
You asked the Plan to pay for a pneumatic compression device. You say that you would like to be reimbursed 
by the Plan because this item was medically necessary. The Plan denied your request. The Plan says this item is 
statutorily not covered by Medicare. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided 
that the Plan does not have to pay for a pneumatic compression device (E0676) provided on December 14, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided from March 3, 2021, to April 
28, 2021. 
 
You asked the Plan to pay for chiropractic services. You say that this has been covered in the past. The Plan 
denied your request. The Plan says this is not covered for your condition. 
 
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 rules also 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. Neither you nor your provider has submitted medical records to 
support these services. The diagnosis codes submitted do not indicate that you have a subluxation. Based on 
this information, we decided that Medicare rules for coverage of chiropractic services have not been met. 
Therefore, we decided that the Plan does not have to pay for chiropractic services provided from March 3, 
2021, to April 28, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ground mileage (A0425) and non-
emergency ambulance transportation (A0428) provided on September 25, 2020. 
 
You asked the Plan to waive the copayment for the ground mileage and non-emergency ambulance 
transportation. The Plan denied your request. The Plan says the enrollee is responsible for a $250 copay for 
ground travel ambulance services, but because the cost share was less than the standard copay, you paid the 
lesser 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).  
The enrollee's contract with the Plan clearly says that enrollees must pay a $250 copay for ground travel for 
Ambulance services.  
 
The enrollee has been asked to pay less than a $250 copay for ground travel for the ground mileage and non-
emergency ambulance transportation because the cost share was less than the standard $250 copay. The ground 
mileage and non-emergency ambulance transportation falls within the Ambulance services benefit category. 
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 the ground mileage (A0425) and non-
emergency ambulance transportation (A0428) provided on September 25, 2020.