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

We decided that the Plan does not have to pre-approve definitive drug testing of 15-21 drug classes. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that definitive drug testing is covered when specific criteria are 
met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if 
the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not 
medically necessary. Our physician reviewer found the records show that you have unclassified pain. There is no 
documentation to support medical necessity of this testing. There is no information supporting a need to test 15 or more 
drugs in your system. The testing is not reasonable or medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare 
rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve 
definitive drug testing of 15-21 drug classes.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the co payment for the CT scan provided. 
 
You asked the Plan to reduce the co payment for the CT scan. You say that you were not admitted to the 
hospital, you were in the ER for a few hours. You say that your insurance card says $60 for an ER visit. The 
Plan denied your request. The Plan says the co payment applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
co payments, deductibles and coinsurance). Your contract with the Plan clearly says that if advanced imaging 
services are received as part of an emergency department evaluation then you will only pay the advanced 
imaging co payment, not the emergency room copayment. Your contract with the Plan clearly says that you 
must pay a $175 co payment for each Medicare-covered advanced imaging service.  
 
You have been asked to pay a $175 co payment for the CT scan. The CT scan falls within the "Outpatient 
diagnostic tests and therapeutic services and supplies" 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 reduce the copayment for the CT scan provided.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray services coded 72110 provided on July 17, 2020. 
 
You asked the Plan to pay for the x-ray services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered are not payable as billed. 
 
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 72110 is radiologic examination, spine, lumbosacral; 
minimum of 4 views. 
 
We find that CPT code 72110 is not supported in the medical record. Specifically, the provider of this service is 
not certified for services. Until the provider is site certified, these charges are not payable. Based on this 
information, we decided that Medicare rules for coverage of the x-ray services have not been met. Therefore, 
we decided that the Plan does not have to pay for the x-ray services coded 72110 provided on July 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab work provided 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. You say that this lab work was requested by a provider. 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. The Plan says that the referring provider is also out-of-network. 
 
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 by an out of 
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physician's services provided on June 12, 2020. 
 
You asked the Plan to waive the copayment for the physician's services. The Plan denied your request. The 
Plan says the $40 copay for falls under your Vision Care benefits for Medicare Covered Vision Services at a 
specialist's office. 
 
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 $40 
copayment for vision care, Medicare covered vision services.  
 
You have been asked to pay $40 copayment for the physician's services. The physician's services fall within the 
vision care, Medicare covered vision 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 copayment 
for physician's services provided on June 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549 
provided on December 6, 2019. 
 
You asked the Plan to pre-approve the compression stockings. You say that your doctor tried to acquire 
preauthorization but you received no letters or other notifications. The Plan denied your request. The Plan says 
the denial of payment for these compression stockings is correct, because these are not covered. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6549 provided on December 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services rendered on December 22, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 99291 is not supported. 
 
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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, there is no documentation of 
30-74 minutes of critical care spent on the enrollee. 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 critical care services rendered on December 22, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Single-Photon Emission Computed Tomography 
(SPECT) test. 
 
You asked the Plan to pre-approve SPECT test. You say that your physician is looking for inflammation that 
would pinpoint the cause of your pain. The Plan denied your request. The Plan says the denial of authorization 
for this test is correct, because this SPECT test is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically 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 SPECT test. Our reviewer says that you 
do not meet the Medicare criteria for the requested SPECT test. Our physician reviewer found you are 
requesting a SPECT test, but you do not have a history of cancer or inflammatory disease. A Computed 
Tomography (CT) scan is an excellent imaging choice for evaluating the sacroiliac (SI) joint, but the requested 
SPECT test is 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 SPECT test have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Single-Photon Emission Computed Tomography (SPECT) test.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-rays provided on July 17, 2020. 
 
You asked the Plan to pay for the chest x-rays (71046). You say that the Plan should pay this claim. The Plan 
denied your request. The Plan says the site is not certified by Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a provider from 
a site not certified by Medicare. 
 
The services at issue in this appeal were provided in a site not certified by Medicare. Therefore, we decided 
that the Plan does not have to pay for the chest x-rays provided on July 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging services rendered on May 22, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure codes 77066 and 76642-26-RT and 76642-26-LT are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 77066 is 1. You billed 2 units of this code, exceeding the MUE. The MUE 
for CPT code 76642 is 1. You billed 2 units of this code, exceeding the MUE. 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 imaging services rendered on May 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room services rendered on April 28, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not filed timely. 
 
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 these services was not filed until July 28, 2020. A valid Waiver of Liability 
(WOL) was not received until September 8, 2020. This means that more than one calendar year from the date 
of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the 
emergency room services rendered on April 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit provided on July 1, 2020, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for a specialist office visit. 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 for 
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 a specialist office visit provided on July 1, 2020, 
by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for direct skilled nursing services (HCPCS G0299) provided to 
the enrollee on June 8, 2020. 
 
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 this needs to be re-billed. 
 
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 G0299 is "Direct skilled nursing services of a 
registered nurse (RN) in the home health or hospice setting, each 15 minutes." 
 
We find that HCPCS code G0299 is not supported in the medical record. Specifically, the records show that it 
was billed on a 1500 claims form, rather than the correct UB04/CMS-1450 form. 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 direct skilled nursing services (HCPCS G0299) provided to the enrollee on June 8, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the out-of-network office visits provided. 
 
You asked the Plan to waive the coinsurance for the office visits. You say that the provider was in-network on the date of 
service. The Plan denied your request. The Plan says the coinsurance applied 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 50% of the total 
cost for Medicare-covered, out-of-network, physician specialist services.  
 
You have been asked to pay a total of $163.78 for the office visits.  
 
Date of Service Service Allowed Amount Coinsurance Member Liability 
Office Visit $215 50% $107.50 
Office Visit $112.56 50% $56.28 
TOTAL:    $163.78 
 
The office visits fall within the "Physician/Practitioner services, including doctor's office visits" benefit category. The 
records show that the provider is out-of-network. 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 coinsurance for the out-of-network office visits 
provided.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care received on June 25 to June 30, 2020. 
 
You asked the Plan to pay for SNF care. You say that these services were required and coverable under Medicare. 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 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 SNF care. Our reviewer says that daily skilled services are not 
necessary. Our physician reviewer found that the enrollee received physical therapy (PT) and occupational therapy (OT) 
in the SNF. By the dates in question, the enrollee was at a moderate assist to dependent assist level with functional 
mobility and required a mechanical lift for transfers. The enrollee required varying assist with activities of daily living 
(ADLs). There were no identifiable skilled nursing or skilled therapy service needs. The enrollee did not meet severity of 
illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. 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 
received on June 25 to June 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the urgent care visit provided on August 5, 
2020. 
 
You asked the Plan to reduce the copayment for the urgent care visit. You say that you only paid $5 for a 
previous urgent care visit. The Plan denied your request. The Plan says the copayment applied 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 $50 
copayment for urgently needed services.  
 
You have been asked to pay a $50 copayment for the urgent care visit. The urgent care visit falls within the 
"Urgently needed 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 reduce the copayment for the urgent 
care visit provided on August 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bridge for teeth # 13, 14 and 15, and core build up for teeth # 13 
and 15. 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee needs a bridge for teeth # 13, 14, and 15. 
You say that teeth # 13 and 15 have large existing amalgam fillings. You say that crowns and build up are needed due to 
decay. You also say that the enrollee experiences pain when biting on the are near tooth # 14. The Plan denied your 
request. The Plan says that this service is not covered. The Plan says that 3 unit bridges are only covered to replace 1 
missing anterior tooth. The Plan says that the requested bridge is to replace a missing posterior tooth. 
 
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. The Plan covers the dental services when the 
services are medically necessary and reasonable.  
 
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 dental services. Our reviewer says that the bridge and core 
build up are not medically necessary. Our physician reviewer found the provided documentation indicates that tooth # 14, 
a posterior tooth, is missing. The reviewer found that according to the rules of coverage, a fixed bridge replacing a 
posterior tooth is not a covered expense. The reviewer also found that the documentation provided does not support the 
need for core buildups for teeth # 13 and 15. Therefore, the reviewer found that the requested services are not medically 
reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's 
rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does not have to pre-
approve a bridge for teeth # 13, 14 and 15, and core build up for teeth # 13 and 15.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the creatinine assay rendered on May 27, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 82565 is not supported. 
 
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 82565 is assay of reatinine; blood. 
 
We find that CPT code 82565 is not supported in the medical record. Specifically, there are no records for these 
services for the date of service at issue. 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 creatinine 
assay rendered on May 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extraspinal manipulation (98943) provided by a chiropractor. 
 
You asked the Plan to pay for extraspinal manipulation. You say that you were told this would be covered. The 
Plan denied your request. The Plan says this is not a covered chiropractic service. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for extraspinal manipulation (98943) provided by a chiropractor.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for the office visit provided on April 23, 2020 and May 7, 2020. 
 
You asked the Plan to waive the copayment for the office visits. You say that you were not informed you 
would have a copayment. You say that you can't pay $35 every time you see the doctor. The Plan denied your 
request. The Plan says that the copayments applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan clearly says that enrollees pay a $0 copayment for provider and professional services at 
an in-network PCP's office.  
 
The Plan says you must pay a $35 copayment for each visit for a specialist visit. Based on the Plan contract, 
however, you cannot be asked to pay more than a $0 copayment for each office visit. The records show that 
you were seen at a family medicine office, which is considered a primary care physician. Therefore, we decided 
that the Plan has to waive the copayment for the office visit provided on April 23, 2020 and May 7, 2020.