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

 
We decided that the Plan does not have to pay for the laboratory services coded 80157, 80177, 80201, 80162, 
80159, and 80173 provided on January 6, 2020. 
 
You asked the Plan to pay for the laboratory services. 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. 
 
We find that CPT codes 80157, 80177, 80201, 80162, 80159, and 80173 are not supported in the medical 
record. Specifically, the documentation does not support that the Carbamazepine, Levetiracetam, Topiramate, 
Digoxin, Clozapine, and Haloperidol testing were performed with blood sampling. Blood specimen collection 
is by venipuncture, however, the lab requisition states a urine specimen was collected; therefore, the billed 
service cannot be verified. 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 80157, 80177, 80201, 80162, 80159, and 80173 provided on January 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copay for the inpatient hospital care provided from May 
28, 2020, to June 4, 2020. 
 
You asked the Plan to waive the copay for the inpatient services. You say that the services were unauthorized 
by you. The Plan denied your request. The Plan says cost sharing is a contractual obligation, and cannot be 
waived. 
 
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 $390 
copay each day for days 1-4 for inpatient mental health care.  
 
You have been asked to pay a $390 copay each day for days 1-4 of the inpatient services. The services fall 
within the inpatient mental health 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 copay for the 
inpatient hospital care provided from May 28, 2020, to June 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
December 13, 2019 to December 20, 2019. 
 
You asked the Plan to pay for home health services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the Medicare rule for payment of this claim has 
not been met. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the 
submitted claim does not include the required treatment authorization or Q codes. Therefore, we decided that 
the Plan does not have to pay for the home health services provided to the enrollee from December 13, 2019 to 
December 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses received on June 23, 2020. 
 
You asked the Plan to pay for the eyeglasses. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services received are 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 eyeglasses once every two years. 
 
We looked at the file and the Plan's rules. Review of the file shows that you received an eye exam and 
eyeglasses on June 23, 2020. You previously received eyeglasses on July 8, 2019. Two years had not passed 
since you previously received eyeglasses. Based on this information, we decided that the Plan's rules for 
 
 
coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for the 
eyeglasses received on June 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay on May 12 to 
May 25, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you should never have 
been discharged on May 16, 2020. The Plan denied your request. The Plan says the correct copayment was 
applied. 
 
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 $385 
copayment for each day of each admission for days 1-5 of covered hospital stays.  
 
You have been asked to pay $1,925, or a $385 copayment for each day of days 1-5 of an inpatient hospital stay. 
An 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 on May 12 to May 25, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care from June 7 to June 12, 2020. 
 
You asked the Plan to pay for SNF care. You say that the enrollee needed SNF care. The Plan denied your 
request. The Plan says rules for SNF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered.  
 
We looked at the file and Medicare rules. The case record documents that the enrollee was not physically 
present in the SNF from June 7 to June 12, 2020. Based on this information, we decided that Medicare rules for 
coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pay for SNF 
care from June 7 to June 12, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for molecular genetic screening testing (CxBladder) provided to 
the enrollee on June 1, 2020. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says Medicare says screening services with no relation to a medical diagnosis of disease for the health 
of the patient are not a benefit. 
 
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 the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found Cxbladder is considered experimental/investigational. The review has determined that the items/services 
at issue in this case are not medically reasonable and 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 the testing have not been met. Therefore, we decided that the Plan does not have 
to pay for molecular genetic screening testing (CxBladder) provided to the enrollee on June 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit for evaluation and management of established 
patient (99349) provided on April 13, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for home visit. You say that telemedicine does not require prior authorization. The 
Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services 
rendered by an out-of-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan 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 home visit for evaluation and management of 
established patient (99349) provided on April 13, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the eye refraction provided on June 16, 2020. 
 
You asked the Plan to pre-approve the eye refraction. You say that this should be covered by the Plan. The Plan 
denied your request. The Plan says that this is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The services you asked the Plan to pre-approve are considered routine vision services or eyewear. Therefore, 
we decided that the Plan does not have to pre-approve the eye refraction provided on June 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve right hip surgery for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show a detailed picture study that shows advanced joint disease of the 
hip. 
 
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 pre-approve the surgery. Our reviewer says that the 
requested surgery is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the surgery is not needed. More conservative measures are required. Surgery criteria not met. A recent 
trial of PT is needed. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve right hip surgery for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a positron emission tomography (PET) scan (78815) 
provided on April 30, 2020. 
 
You asked the Plan to pay for a PET scan. You say that this was billed with the correct diagnosis. The Plan 
denied your request. The Plan says the billed diagnosis is not valid for this service. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans must be billed with an appropriate 
diagnosis code.  
 
We looked at the file and Medicare rules. The billed diagnosis code, C85.90, is not listed as an appropriate 
code. Based on this information, we decided that Medicare rules for coverage of a PET scan have not been met. 
Therefore, we decided that the Plan does not have to pay for a positron emission tomography (PET) scan 
(78815) provided on April 30, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to 
the enrollee on May 18, 2020. 
 
You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your 
request. The Plan says as Comprehensive Genomic Profile (CGP) testing is not defined as a targeted panel by 
MolDX; and it is a test not currently satisfactorily described by any existing CPT code; to report a CGP, 
service providers should use CPT code 81479 (for the entire multi-test panel) at this time, in addition to the 
approved DEX Z-Code TM entered adjacent in the comment/narrative field for the test; not unbundled to 
separate codes.  
 
 
Coverage of CGP is limited to one test per specimen and precludes the use of any other molecular testing on 
the specimen. The Plan states this is an administrative determination for coding and is not based on clinical 
criteria for medical necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT 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 claim is missing the main code 
and identifier required by Medicare for coverage of this testing. Based on this information, we decided that 
Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have 
to pay for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on May 18, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Hydromorphone (J1170) and Bupivacaine (J3490) provided 
from June 12, 2020, to July 14, 2020. 
 
You asked the Plan to pay for Hydromorphone and Bupivacaine. You say that you do not know why you are 
being charged. The Plan denied your request. The Plan says these drugs are not FDA approved for this use. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Hydromorphone and Bupivacaine. Our 
reviewer says that the use of Hydromorphone and Bupivacaine is not supported in this case. Our physician 
reviewer found neither Hydromorphone or Bupivacaine are FDA approved for intrathecal administration or 
intrathecal implanted pump use. Also, any mixture of two or more different kinds of medicines to be used in a 
pump will not be covered. The documentation does not support that the Hydromorphone and Bupivacaine was 
medically reasonable and 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 Hydromorphone and Bupivacaine have not been met. Therefore, we decided 
that the Plan does not have to pay for Hydromorphone (J1170) and Bupivacaine (J3490) provided from June 
12, 2020, to July 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of skin and/or muscle (11043) provided on 
March 31, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the removal of skin and/or muscle. You say that the services provided were 
medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained by the 
facility or the provider; therefore, payment has been correctly denied. 
 
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 removal of skin and/or muscle (11043) 
provided on March 31, 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 the neuromuscular stimulator provided on May 1, 2020. 
 
You asked the Plan to pay for the provided service. You say that the medical records prove medical necessity. 
The Plan denied your request. The Plan says the enrollee's geographical area does not qualify for telehealth 
services. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 ordered following the non-covered visit are likewise non-
covered. Therefore, we decided that the Plan does not have to pay for the neuromuscular stimulator provided 
on May 1, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive consultation (88325) provided on 
February 13, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for comprehensive consultation. You say that the services rendered were medically 
necessary. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent 
services rendered by an out-of-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan 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 comprehensive consultation (88325) provided 
on February 13, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are no complex nursing or medical needs requiring a resource-intensive inpatient 
hospital setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require an intensive inpatient rehabilitation therapy program. Based on the medical records provided, 
there is concern that the enrollee will not be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an inpatient rehabilitation facility. Care at the skilled nursing facility 
level appears to be more appropriate 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have pay for lab testing provided to the enrollee under codes 80345, 80323, 
80346, and 80325.  
 
You asked the Plan for this testing which you say was medically necessary. The Plan denied your request. The 
Plan says that based on the Medicare guidelines, the codes billed on this claim are not payable by Medicare. 
The Plan says that following the National Correct Coding Initiative Policy Manual for Medicare Services, 
Chapter 10, beginning January 1, 2017, presumptive drug testing may be reported with CPT codes 80305-
80307. These codes differ based on the level of complexity of the testing methodology. Only one code from 
this code range may be reported per date of service. The guidelines also state that beginning January 1, 2016, 
definitive drug testing may be reported with HCPCS codes G0480-G0483. These codes also differ based on the 
number of drug classes including metabolites tested. On January 1, 2017, HCPCS code G0659 defining a 
different type of definitive drug testing was added. Only one code from this group of codes may be reported per 
date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, this claim cannot be paid due to an issue 
with codes submitted based on the Medicare billing guidelines for this type of testing. The Plan states a 
corrected claim would be accepted.  Therefore, we decided that the Plan does not have to pay for lab services 
provided to the enrollee on November 7, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture. 
 
You asked the Plan to pre-approve the maxillary partial denture. You say that your current partial dentures are 
broken, cracked, and hurt your gums. The Plan denied your request. The Plan says this service is allowed one 
time every 60 months. The Plan also says that you received this service less than 60 months ago. 
 
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, dentures are limited to one set every 5 
years. The record shows that you received a maxillary partial denture on January 25, 2018, and your maxillary 
denture benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a 
maxillary partial denture.