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

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that you are in pain. The Plan denied your request. The 
Plan says the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Euflexxa. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found you have a diagnosis of osteoarthritis of the knee. The record provided is insufficient to 
document the failure of conservative nonpharmacologic therapy or to simple analgesics. The Food and Drug 
Administration has not stated that the requested drug is indicated for the enrollee's condition. Therefore, the 
enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
January 7, 2023, to January 10, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged 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 $200 
copayment per day for days 1-6 of an inpatient hospital stay. 
 
 You have been asked to pay a total of $600, which is a $200 copayment per day for days 1-3 of the inpatient 
hospital stay ($200 copayment x 3 days = $600). You are not being charged for the day you were discharged. 
This item/service 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. 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 inpatient hospital stay provided from January 7, 2023, to January 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ophthalmoscopy (92201) provided on March 30, 2023.  
You asked the Plan to pay for an ophthalmoscopy (92201). You say the doctor agreed that your extended 
ophthalmoscopy (92201) would be covered. The Plan denied your request. The Plan says an ophthalmoscopy 
(92201) is not a covered service. 
 
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 one routine eye examination every year. The Plan contract also says that they cover 
up to $200 for eyeglasses or contact lenses every year. 
 
We looked at the file and the Plan's rules. The Plan rules say that the Plan covers one routine eye examination 
every year. The Plan rules also says that they cover up to $200 for eyeglasses or contact lenses every year. An 
ophthalmoscopy (92201) is not a covered benefit. Based on this information, we decided that the Plan's rules 
for coverage of an ophthalmoscopy (92201) have not been met. Therefore, we decided that the Plan does not 
have to pay for an ophthalmoscopy (92201) provided on March 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics.  
 
You asked the Plan to pay for foot orthotics. You say that you should not have to pay for the arch support 
because you have issues with your feet that are causing pain. 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 pay for foot orthotics.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81479 for date of service  
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the claim for this molecular pathology testing did not include the 
required unique identifier. 
 
 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the laboratory services 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 
81479 for date of service
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intravenous moderate (conscious) sedation/analgesia  each 
subsequent 15-minute increment (D9243) provided on January 9, 2023. 
 
You asked the Plan to pay for the dental services. You say that you do not agree with the denial of service. The 
Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
  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. This benefit includes the Plan 
reimbursement up to $2,100 every year for non-Medicare covered preventive dental services and non-Medicare 
covered comprehensive dental services combined. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan paid $193 ($77 + $116 = $193) for date of service January 9, 2023, $413 ($65 + $163 + $48 + 
$48 + $89 = $413) for date of service February 22, 2023, and $1,494 ($243 + $194 + $194 + $194 + $194 + 
$194 + $194 + $87 = $1,494) for date of service March 6, 2023. Therefore, your annual maximum benefit of 
$2,100 has been exhausted on date of service March 6, 2023. Therefore, we decided that the Plan does not have 
to pay for intravenous moderate (conscious) sedation/analgesia  each subsequent 15-minute increment 
(D9243) provided on January 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the contact lenses provided on January 6, 2023.  
You asked the Plan to pay for the contact lenses. You say that you were told by the provider that they accepted 
your insurance. You say you have asked the Plan for a list of network providers and have not received it. 
 The Plan denied your request. The Plan says the service is not a covered benefit. 
 
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 by a network provider. 
 
We looked at the file and the Plan's rules. Specifically, the provider is out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of the contact lenses have not been met. Therefore, 
we decided that the Plan does not have to pay for the contact lenses provided on January 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 2, 2023. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. 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 provided on March 2, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from February 14, 
2023, through February 15, 2023.  
 
 
 
You asked the Plan to pay 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 the acute inpatient hospital care provided 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 these services. 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 enrollee had knee pain due to osteoarthritis and had a planned and approved elective 
total right knee arthroplasty procedure. This is a request for payment of the inpatient services following this 
procedure that is typically performed in an ambulatory center. However, the provided documentation did not 
reveal the enrollee with an unstable condition or at high risk for complication to expect the enrollee would 
require hospital services that would likely cross two midnights for this procedure. The enrollee underwent the 
procedure without complication, her pain was managed, she tolerated oral intake, and was able to ambulate on 
postoperative day one.  
 
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 pay for the acute inpatient hospital care provided from February 14, 2023, through February 15, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on January 18, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you should 
not be responsible for the bill because you did not personally call for the ambulance. You also say you don't 
want the ambulance service to go without being paid, but you don't want to pay it yourself. The Plan denied 
your request. The Plan says these services are not a covered benefit.  
 
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 January 18, 2023. 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 with no 
transport provided on January 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5257, V5267) purchased 
on November 7, 2022. 
 
You asked the Plan to issue reimbursement 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 the items at issue are not payable 
as they were purchased from an out-of-network provider.  
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract states that hearing aids are covered 
only when purchased from the Plans select hearing aid provider. However, the hearing aids in this case were 
purchased from an out-of-network provider. Therefore, we decided that the Plan does not have to issue 
reimbursement for the hearing aids (V5257, V5267) purchased on November 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatments (97810, 97811) provided on 
March 7, 2023. 
 
You asked the Plan to pay 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 the acupuncture services in this case are not 
payable as they were not rendered on the basis of a covered diagnosis.  
 
 
 
  
 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the acupuncture services in this case were not 
rendered on the basis of a diagnosis for chronic low back pain. Therefore, we decided that the Plan does not 
have to pay for  the acupuncture treatments (97810, 97811) provided on March 7, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for discission of secondary membranous cataract surgery 
provided on November 30, 2022. 
 
You asked the Plan to pay for cataract surgery. You say that this should be paid. The Plan denied your request. 
The Plan says the provider was not in-network at the time of these services. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
opted out of the Medicare program until January 24, 2023. Therefore, we decided that the Plan does not have to 
pay for discission of secondary membranous cataract surgery provided on November 30, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code J3490 for date of service April 3, 2023. 
 
You asked the Plan to pay for code J3490. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services billed are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that when a surgery is performed, certain services are 
included in the price of the surgery itself and are not separately payable. 
 
We looked at the file and Medicare rules. We looked at the file and Medicare rules. Review of the file shows 
that surgery procedure 27096 was provided on April 3, 2023. Code -- has a global surgery value of 00 days. 
Code J3490 was billed within the global surgery period of procedure 27096 without an appropriate modifier.  This means code 27096 is not separately payable as billed. Based on this information, we decided that 
Medicare rules for coverage of code J3490 have not been met. Therefore, we decided that the Plan does not 
have to pay for code J3490 for date of service April 3, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, emergency transport 
and ground mileage provided on February 3, 2022. 
 
You asked the Plan to pay for the ambulance service, basic life support, emergency transport and ground 
mileage. You say that the ambulance services were the result of an auto accident. You also say that the delay in 
submission resulted from due diligence efforts to determine if third party liability coverage was available. The 
Plan denied your request. The Plan says the claim was untimely, and the submission did not meet the exception 
criteria guidelines. 
 
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 ambulance service, basic life support, emergency transport and ground 
mileage was not filed until March 24, 2023. 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 
ambulance service, basic life support, emergency transport and ground mileage provided on February 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a shower chair or bench.  
 
You asked the Plan to pay for a shower chair. You say that you would like reconsideration because the 
requested shower chair is medically necessary. 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 shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pay for a shower chair or bench.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for fundus photography (92250) provided on January 14, 2023. 
 
You asked the Plan to pay for fundus photography (92250). You say that you only continue the photos from a 
preventative perspective given the pre-diabetic diagnosis. The Plan denied your request. The Plan says there is 
no coverage for fundus photography (92250). 
 
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 one eye examination per calendar year. 
 
We looked at the file and the Plan's rules. The Plan rules say they cover one eye examination per year. Fundus 
photography is not covered under this benefit. Based on this information, we decided that the Plan's rules for 
coverage of fundus photography (92250) have not been met. Therefore, we decided that the Plan does not have 
to pay for fundus photography (92250) provided on January 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composite - three surfaces, posterior (D2393), 
resin-based composite - two surfaces, anterior (D2331), pulp cap - indirect (excluding final restoration) 
(D3120), resin-based composite - one surface, anterior (D2330) provided on February 10, 2022. 
 
You asked the Plan to pay for the dental services represented by codes D2393, D2331, D3120 and D2330. The 
Plan denied your request. The Plan says the claim was untimely, and the submission did not meet the exception 
criteria guidelines. 
 
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 dental services represented by codes D2393, D2331, D3120 and D2330 
was not filed until March 17, 2023. 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 resin-based 
composite - three surfaces, posterior (D2393), resin-based composite - two surfaces, anterior (D2331), pulp cap 
- indirect (excluding final restoration) (D3120), resin-based composite - one surface, anterior (D2330) provided 
on February 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 18, 2023, billed 
with codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81335, 81479, and 
81238. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code.  
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
February 18, 2023, billed with codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 
81335, 81479, and 81238.