Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each physical therapy (PT) service 
provided on July 14, 2022, to December 15, 2022. 
 
You asked the Plan to waive the copayment for each physical therapy (PT) service. You say that you should 
not be responsible for the copayments because the physical therapy services received did nothing for you. 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 $25 
copayment for outpatient rehabilitation service. 
 
You have been asked to pay a $25 copayment for each physical therapy (PT) service. This item/service falls 
within the outpatient rehabilitation service 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 each physical therapy (PT) service provided on July 14, 2022, to December 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted molecular pathology procedure, Cxbladder 
Triage test (81479) provided May 25, 2021. 
 
You asked the Plan to pay for Cxbladder Triage test. You say that you believe that the evidence supporting use 
of Cxbladder Triage test as a medically necessary diagnostic service is well established. The Plan denied your 
request. The Plan says the documentation does not support that the services rendered were medically necessary. 
 
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 pay for Cxbladder Triage test. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found Cxbladder is not considered a screening test for urothelial cancer. Cystoscopy, 
ureteroscopy, possible biopsy and upper tract imaging will still be necessary regardless of the results of 
Cxbladder testing. Current AUA Guidelines do not recommend CxBladder for bladder cancer screening or 
monitoring. Cxbladder Triage test is not medically reasonable and necessary 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 Cxbladder Triage test have not been met. Therefore, we decided that the Plan 
does not have to pay for the unlisted molecular pathology procedure, Cxbladder Triage test (81479) provided 
May 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a freestyle libre 3 continuous glucose monitor (CGM) 
sensor. 
 
You asked the Plan to pre-approve the freestyle libre 3 CGM. You say that the items should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the items denied correctly as the freestyle 
libre 3 is not the Plan's preferred brand. 
 
  The Plan must follow Medicare rules. Medicare rules say that a non-adjunctive continuous glucose monitor 
(CGM) must be billed with code E2103. The rules also say that only devices reviewed by the PDAC and 
assigned code E2103 may be billed using this code.  
 
We looked at the file and Medicare rules. The request at issue is for the Freestyle Libre 3 non-adjunctive CGM. 
However, this device has not been reviewed by the PDAC and has not been assigned code E2103. As such, this 
non-adjunctive CGM device is not eligible for coverage at this time. Therefore, we decided that the Plan does 
not have to pre-approve a freestyle libre 3 continuous glucose monitor (CGM) sensor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair lift. 
 
You asked the Plan to pre-approve a stair lift. You say that the medical records provided support that a stair lift 
is medically necessary. The Plan denied your request. The Plan says the requested item is not medically 
necessary because it is useful in the absence of disease and is not primarily medical in nature. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift 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 pre-approve a stair lift.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Cxbladder Detect (0012M) provided November 17, 2022. 
 
You asked the Plan to pay for genetic testing. You say that you are appealing the denial of coverage for the 
Cxbladder Detect test. The Plan denied your request. The Plan says this testing does not meet Medicare criteria 
and is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for 
Cxbladder Detect (0012M) provided November 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 81003 and 87635 billed for date of service 
October 14, 2022, to October 15, 2022. 
 
You asked the Plan to pay for procedure codes 81003 and 87635. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says payment for code 81003 is 
bundled into payment for code 80307. Additionally, you billed code 87635 with the CS modifier. This code is 
not on the coinsurance waiver eligible list. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules also say that code 87635 is not 
an eligible code for the CS modifier to be billed as this code is not on the coinsurance waiver eligible list. The 
whole claim will be rejected and returned to provider until the error is corrected. In this case, we have 
confirmed that code 81003 is a column II code to column I code 80307. This claim has not been billed with an 
appropriate modifier to bypass the edit. Additionally, you billed code 87635 with the CS modifier. This code is 
not on the coinsurance waiver eligible list. Based on the claim submitted, Medicare billing criteria have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure codes 81003 and 87635 billed 
for date of service October 14, 2022, to October 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Reflux Relief System (E1399). 
 
You asked the Plan to pre-approve a retail pillow. You say that due to ongoing neck problems, you have 
encountered quite a few issues with sleeping. The requested item has been checked out by your provider and he 
feels that this system will help with the acid that is irritating your esophagus and vocal cords. The Plan denied 
your request. The Plan says the requested item is a retail pillow and not DME. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 
 The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a Reflux Relief System (E1399).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral x-ray (D0120) provided on September 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service December 03, 2020. 
Therefore, we decided that the Plan does not have to pay for an intraoral x-ray (D0120) provided on September 
6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you want these benefits approved. The Plan 
denied your request. The Plan says the criteria for eligibility have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
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 19, 2022, and May 29, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you were 
unaware that you did not have coverage for this service. 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 19, 2022, and May 29, 2022. The 
ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays 
for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response 
and treatment with no transport provided on January 19, 2022, and May 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for complete denture- maxillary (D5110) and mandibular partial 
denture (D5214) provided on January 5, 2023. 
 
You asked the Plan to pay for complete denture- maxillary and mandibular partial denture. You say that this 
should be covered. The Plan denied your request. The Plan says these are not covered services. 
 
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 complete 
denture- maxillary (D5110) and mandibular partial denture (D5214) provided on January 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental cleaning (D1110) provided on December 27, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the dental service was received from an out-
of-network, unassigned dental provider and is not covered by your supplemental benefits. 
 
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. 
 
The record shows you received the dental service from an out-of-network, unassigned dental provider. Though 
the Plan offers a dental benefit in excess of Medicare coverage, the service provided is not covered under this 
benefit when received from an out-of-network, unassigned dental provider. Therefore, we decided that the Plan 
does not have to pay for the dental cleaning (D1110) provided on December 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing coded 81479 for date of service August 
29, 2022. 
 
You asked the Plan to pay for the laboratory testing coded 81479. 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 testing 
coded 81479 have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
testing coded 81479 for date of service August 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on January 11, 2023, billed with 
code 78452. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim was billed with an incorrect place of 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code assigned shall be in the same 
setting in which the services were received.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the imaging services provided. have not been met. The file shows that the enrollee was an inpatient 
on the date of service. As such, the outpatient POS code 22 is not appropriate. Therefore, we decided that the 
Plan does not have to pay for imaging services provided on January 11, 2023, billed with code 78452.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the frames (V2020), single vision lens (V2103), and 
anti-reflective coating (V2750) provided on January 6, 2023. 
 
You asked the Plan to pay more for the eyewear. You say that based on the coverage agreement, you had a 
$200 benefit for eyewear. The Plan denied your request. The Plan says the benefits have been applied correctly. 
 
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 a $200 allowance every calendar year for eyewear to correct vision. 
 
We looked at the file and the Plan's rules. The record shows that this full $200 allowance was used on this 
purchase, and you are responsible for the remaining balance of $439, which was paid at the time of purchase. 
Based on this information, we decided that the Plan's rules for coverage of the eyewear have not been met. 
Therefore, we decided that the Plan does not have to pay more for the frames (V2020), single vision lens 
(V2103), and anti-reflective coating (V2750) provided on January 6, 2023.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for a radiologic examination, upper gastrointestinal tract (x-ray) provided 
on October 27, 2022, billed with procedure code 74240. 
 
You asked the Plan to pay for the x-ray. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says that Medicare rules for payment of this claim have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. there is no documentation if procedure code 74246 was used on the same day. 
Therefore, we decided that the Plan has to pay for a radiologic examination, upper gastrointestinal tract (x-ray) 
provided on October 27, 2022, billed with procedure code 74240.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter to be provided by an OON provider. 
 
You asked the Plan to pre-approve a power scooter. The Plan denied your request. The Plan says that this item 
is not covered when received from an OON 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 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 power scooter to be provided by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the additional transportation trips. 
 
You asked the Plan to pre-approve the additional transportation trips. You say that you would like more trips 
because you see many specialists. You say you have already used up the available trips. The Plan denied your 
request. The Plan says the benefit has been exhausted. 
  
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve the additional transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup, including any pins when required tooth # 30 
(D2950) provided on January 24, 2023. 
 
You asked the Plan to pay for the core buildup. You say that you thought this service was covered. The Plan 
denied your request. The Plan says the core buildup, including any pins when required (D2950) is not listed as 
a covered 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 core 
buildup, including any pins when required tooth # 30 (D2950) provided on January 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fundus photography with interpretation and report 
(92250) provided on February 17, 2023. 
 
You asked the Plan to pay for the fundus photography. You say that you paid this bill. The Plan denied your 
request. The Plan says this is not a covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that intraocular photography is covered when used 
for the diagnosis of such conditions as macular degeneration, retinal neoplasms, choroid disturbances and 
diabetic retinopathy, or to identify glaucoma, multiple sclerosis and other central nervous system abnormalities. 
 
We looked at the file and Medicare rules. The record shows that your diagnoses are Hypermetropia, bilateral 
(near sightedness) and Regular astigmatism, bilateral. These diagnoses are not covered conditions. Based on 
this information, we decided that Medicare rules for coverage of the fundus photography have not been met. 
Therefore, we decided that the Plan does not have to pay for the fundus photography with interpretation and 
report (92250) provided on February 17, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for air ambulance service provided on September 27, 2022. 
 You asked the Plan to pay for the air ambulance service. You say that it is our desire to work cooperatively to 
resolve this denial on behalf of our patient. The Plan denied your request. The Plan says after reassessing the 
entire clinical situation, information provided at the time of the appeal does not support criteria for air 
ambulance transport. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 the air ambulance service. Our reviewer says 
that the air ambulance transport was not medically necessary. Our physician reviewer found the documentation 
does not support that the enrollee suffered from an illness or injury that contraindicates transportation by any 
means other than ambulance. 
 
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 air ambulance service have not been met. Therefore, we decided that the 
Plan does not have to pay for air ambulance service provided on September 27, 2022.