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

 
We decided that the Plan has to pay for drug testing services (HCPCS G0483) provided to the enrollee on June 
21, 2019. 
 
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 that the documentation submitted did not include a valid physician order/lab requisition or 
medical records (signed by the ordering physician); therefore, the billed code cannot be verified.  
 
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 HCPCS code G0483 is "Drug test(s), definitive, utilizing (1) 
drug identification methods able to identify individual drugs and distinguish between structural isomers (but 
not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any 
type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods 
(e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all 
samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or 
drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations 
and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 
or more drug class(es), including metabolite(s) if performed." 
 
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 services. Our reviewers says that the 
services at issue in this case were supported by the medical records. Our physician reviewer found the 
laboratory submitted a valid/signed physician laboratory requisition form, and lab results. The review has 
determined that the records support the denied code. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
drug testing services (HCPCS G0483) provided to the enrollee on June 21, 2019. 
  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copay for the cardiology specialist services provided on 
March 9, 2020. 
 
You asked the Plan to waive the copay for the services provided. You say that you have had services done in 
the past and didn't have a copay. 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 a $35 
copay per visit to a specialist.  
 
You have been asked to pay $32.91 for the services provided. Because the amount is less than your $35 copay, 
you were charged the lesser amount. The services fall within the physician services benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copay for the cardiology specialist services provided on March 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) (K0554 and K0553) 
provided on January 9, 2020. 
 
You asked the Plan to pay for a CGM. You say that this should be covered. The Plan denied your request. The 
Plan says sufficient documentation to support medical necessity has not been submitted. 
 
The Plan must follow Medicare rules. The rules state that CGMs and related supplies are covered by Medicare 
when the beneficiary has been using a BGM and performing frequent (four or more times a day) testing and 
they are insulin-treated with multiple (three or more) daily injections of insulin or a Medicare-covered 
continuous subcutaneous insulin infusion (CSII) pump. 
 
The record does not contain medical records which support medical necessity for the supplies provided in this 
case. The records do not show that the enrollee tests her blood glucose four or more times a day and is treated 
with three or more insulin injections a day. Therefore, we decided that the Plan does not have to pay for a 
continuous glucose monitor (CGM) (K0554 and K0553) provided on January 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5250) purchased October 22, 2019 from 
an out-of-network provider. 
 
You asked the Plan to pay for the hearing aids. You say that you initially went to another provider and the final 
cost was $6,000 which was much more than you could afford. The cost for the hearing aids you purchased was 
much more reasonably priced. The Plan denied your request. The Plan says enrollees must receive their 
hearing services from an in-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 rendered by an in-network provider. The health plan contract specifically says you must 
use a doctor in the network.  
 
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 hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for 
the hearing aids (V5250) purchased October 22, 2019 from an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded G0483 provided on July 22, 2019. 
 
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation 
submitted did not include a valid physician order/lab requisition form or medical records signed by the ordering 
physician for the billed date of service. Based on this information, we decided that Medicare rules for coverage 
of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug 
testing coded G0483 provided on July 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99212) and debridement (97597) provided on 
October 9, 2019. 
 
You asked the Plan to pay for an office visit and debridement. You say that this is the only claim for these 
services. The Plan denied your request. The Plan says a claim for these services was previously paid. 
 
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined 
to be exact duplicates of another claim or claim line are denied.  
 
We looked at the file and Medicare rules. The record shows that the services at issue were paid on a previous 
claim for the same enrollee, provider, date of service, codes, and modifiers. Based on this information, we 
decided that Medicare rules for coverage of an office visit and debridement have not been met. Therefore, we 
decided that the Plan does not have to pay for an office visit (99212) and debridement (97597) provided on 
October 9, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provide to the enrollee on January 9, 2020. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the records provided do not include a valid physicians order. 
 
The Plan must follow Medicare rules. Medicare has specific documentation requirements for this type of 
testing. The physicians order and the medical records must specifically show how this testing will be used to 
treat illness or disease present in the enrollee at the time of service as opposed to this testing being done for 
screening purposes. Based on the records provided, the required Medicare criteria are not met. Therefore, we 
decided that the Plan does not have to pay for drug testing provide to the enrollee on January 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the walker provided on December 6, 2019 by an out of 
network provider. 
 
You asked the Plan to pay for the folding wheeled walker (E0143). You say that the walker was prescribed by 
the enrollee's doctor. The Plan denied your request. The Plan says you did not obtain 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 has network providers 
available who can provide 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 the walker provided on December 6, 2019 by an 
out of network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the injection and the Part B drug provided 
on December 19, 2019. 
 
You asked the Plan to waive the cost share for the injection and the Part B drug. You say that you were told 
that you would have a $45 copayment. You say you cannot afford this amount. The Plan denied your request. 
The Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
copayment for services obtained from an in-network specialist, or under certain circumstances, treatment by a 
nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's office 
and 20% coinsurance for each in-network Medicare-covered Part B drug.  
 
You have been asked to pay a $45 copayment for the injection and $244.80 which is 20% of the allowed 
amount for the Part B drug. The allowed amount is $1,224. ($1,224 x 20% = $244.80). ($45 + $244.80 = 
$289.80). The injection falls within the ?Physician/Practitioner Services, Including Doctor?s Office Visits? 
benefit category. The Part B drug falls within the ?Medicare Part B Prescription Drugs? 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 cost share for the injection and the Part B drug provided on December 19, 
2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing panel provided on September 18, 
2019. 
 
You asked the Plan to pay for the definitive drug testing panel. You say that this was medically necessary and 
should be paid. The Plan denied your request. The Plan says there is no valid order for this testing. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing may be covered when ordered by a 
treating provider. Orders need not be signed but the record must demonstrate the intent that the testing be 
performed.  
 
In this case, an unsigned order for a custom testing profile was included in the file. There is no information 
provided regarding the drug classes included in this panel. There is also no documentation in the progress note 
provided of the intent to perform drug testing. Therefore, we decided that the Plan does not have to pay for the 
definitive drug testing panel provided on September 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services billed to the enrollee from December 1, 
2019 to December 31, 2019. 
 
You asked the Plan to pay for these services. You say that these claims should be paid. The Plan denied your 
request. The Plan says insufficient documentation was submitted to establish a care relationship between you 
and the enrollee. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT codes and provide medical records to support the 
services billed. In this case, the records provided do not clearly establish that you treated the enrollee in 
question. Therefore, we decided that the Plan does not have to pay for medical services billed to the enrollee 
from December 1, 2019 to December 31, 2019.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing services provided on July 2, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services 
were not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab 
requisition stating exactly which testing was to be performed. 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, 2019.
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 
February 23, 2020 to February 29, 2020. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you are requesting to pay a 
lower copayment amount because you did not have a private room at the hospital. The Plan denied your 
request. The Plan says the copayment amount you are being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $390 
copayment per day for days 1 to 5 and $0 copayment for additional days for inpatient hospital stay. This 
inpatient stay lasted 6 days, resulting in a copayment obligation of $1,950. 
 
You have been asked to pay $390 copayment per day for days 1 to 5 and $0 copayment for additional days for 
inpatient hospital stay. Inpatient hospital stay 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 February 23, 2020 
to February 29, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on October 3, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services 
were not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab 
requisition stating exactly which testing was to be performed. 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 October 3, 2019.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the basic metabolic panel, lipid panel, A1C and TSH 
provided on February 3, 2020. 
 
You asked the Plan to pay for the basic metabolic panel, lipid panel, A1C, and TSH. You say that this claim 
has not been paid in full or under the terms of the contract for the services provided to this enrollee. The Plan 
denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare 
covered services related or unrelated to the enrollee's terminal condition. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the basic metabolic panel, lipid panel, A1C and TSH 
provided on February 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on November 5, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering physician's intent that the tests be performed. 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 November 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab work provided on February 25, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and approved for 
payment. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that 
the member's primary care physician did not refer these services. 
 
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 has network providers 
available who can provide 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 lab work provided on February 25, 2020 by an out 
of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bilateral wrist hand orthoses (L3916) provided on February 
25, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the durable medical equipment is medically necessary. 
The Plan denied your request. The Plan says the services are not supported by the records. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for bilateral wrist hand orthoses 
(L3916) provided on February 25, 2020.