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

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you require 
transportation to get to therapy. The Plan denied your request. The Plan says that they will only cover up to the 
benefit maximum. 
 
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 fifty (50) trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plan does not have to provide routine transportation above the Plan benefit maximum of fifty (50) 
routine transportation trips. Therefore, we decided that the Plan does not have to pre-approve additional routine 
transportation trips.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on October 24, 
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 the denied CPT codes remain 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 the denied codes is: 
 
CPT 80157: 
 
Carbamepazine; free 
 
CPT 80177: 
 
Levetiracetam 
 
CPT 80201: 
 
Topiramate 
 
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 reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found blood 
specimen collection is by venipuncture, however, the lab requisition states a urine specimen was collected. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for drug testing services provided to the enrollee on October 24, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on November 25, 2019. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed codes 
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. 
 
We find that the billed CPT codes are not supported in the medical record. Specifically, the services were billed 
as if the specimen was collected by blood sampling. However, the records show that the specimen was 
collected by urine sample. Based on this information, we decided that Medicare rules for coverage of the lab 
services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services 
provided on November 25, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Qsymia for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Qsymia for the enrollee.  
 
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an MRI scan of the lower spinal canal 
(72148) performed on June 8, 2020, and an anesthetic injection for the sacroiliac joint (G0260) received on 
June 9, 2020. 
 
You asked the Plan to waive the copayments for an MRI scan and an anesthetic injection. You say that you 
have never had copayments for these services before. The Plan denied your request. The Plan says the correct 
copayments were 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 $175 
copayment for each Medicare-covered diagnostic imaging service and that you must pay a $350 copayment for 
each outpatient hospital and observation service.  
 
You have been asked to pay a $175 copayment for an MRI scan and a $350 copayment for an anesthetic 
injection. An MRI scan and an anesthetic injection fall within the Outpatient hospital 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 copayments for an MRI scan of the lower spinal canal (72148) performed 
on June 8, 2020, and an anesthetic injection for the sacroiliac joint (G0260) received on June 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the arthrocentesis with ultrasound provided on February 19, 
2020. 
 
You asked the Plan to pay for the arthrocentesis (20611). You say that the Plan should pay this claim. The Plan 
denied your request. The Plan says there is no reference to permanently recorded images to support the billed 
charges. 
 
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 20611 is arthrocentesis, aspiration and/or injection with 
ultrasound guidance, with permanent recording and reporting. 
 
We find that CPT code 20611 is not supported in the medical record. There were insufficient records provided 
(specifically, no ultrasound report) to support the claim billed. Medicare billing criteria are not met. Based on 
this information, we decided that Medicare rules for coverage of the arthrocentesis (20611) have not been met. 
Therefore, we decided that the Plan does not have to pay for the arthrocentesis with ultrasound provided on 
February 19, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (G0483) provided on November 4, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service 
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 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 records do not show that 
definitive drug testing of 22 or more drug classes was performed on the date of service in question. 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 services (G0483) provided on November 4, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on December 19, 2019. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with records. The Plan denied your 
request. The Plan says the denial of payment for these services is correct, because the documentation submitted 
did not include a physician order, lab requisition, or medical records stating exactly which tests were to be 
performed. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific 
lab services is required for covered lab services.  
 
We looked at the file and Medicare rules. The documentation submitted does not include a valid physician 
order or clear intent to order the specific lab services billed on this claim. Based on this information, we 
decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan 
does not have to pay for laboratory testing provided on December 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on 
April 8, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that the enrollee is a resident of a 
nursing home and seen by the nurse practitioner while making daily rounds. These visits are not pre-scheduled 
and therefore authorization was not obtained. The Plan denied your request. The Plan says enrollee's must 
receive their medical services from an in-network provider. Non-emergent services with non-contracted 
providers require prior-authorization prior to services being rendered. 
 
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 subsequent nursing facility care (99308) 
provided on April 8, 2020 by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit on February 17, 
2020. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that the copayment should 
be waived. 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 $90 
copayment for Emergency Care.  
 
You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls 
within the Emergency 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 
emergency room visit on February 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office or other outpatient visit for the evaluation and 
management of an established patient (CPT Code 99214) provided to the enrollee on December 20, 2019. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says two or more diagnosis codes associated to it are mismatched. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. CPT Code 99214 is denied because 
two or more diagnosis codes associated to it are mismatched per the ICD-10-CM Official Guidelines for 
Coding and Reporting. The rules say that some ICD-10-CM codes indicate laterality, specifying whether the 
condition occurs on the left, right or is bilateral. It is not appropriate to report unspecified, or left and right 
diagnosis codes when a more specific (e.g. bilateral) code is available. Therefore, we decided that the Plan does 
not have to pay for office or other outpatient visit for the evaluation and management of an established patient 
(CPT Code 99214) provided to the enrollee on December 20, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical assistant services on a prostatectomy provided by a 
registered nurse (RN) on February 24, 2020. 
 
You asked the Plan to pay for surgical assistant services. You say that this provider should be covered for this 
service. The Plan denied your request. The Plan says this provider is not eligible for payment of surgical 
assistant services. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for surgical assistant services on a 
prostatectomy provided by a registered nurse (RN) on February 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a walking boot (L4361). 
 
You asked the Plan to pay for a walking boot. You say that this code is supported. The Plan denied your 
request. The Plan says this was billed with an incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the Place of Service indicates the place in which 
the item is being used. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a walking boot have not been met. Specifically, the record shows that the claim was billed with 
place of service code 11 (Office). The walking boot is going to be primarily used in the enrollee's home. This 
means that the billed place of service code is not supported. Therefore, we decided that the Plan does not have 
to pay for a walking boot (L4361).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on December 4, 2019. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed codes 
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 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 records do not support 
definitive drug testing of 22 or more drug classes on the date of service in question. We also find that CPT 
codes 80157 and 80177 are not supported in the medical record. These services were billed showing the 
specimen was collected by blood sampling. However, the records show that the specimen was collected by 
urine sample. Based on this information, we decided that Medicare rules for coverage of the lab services have 
not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on 
December 4, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on April 3, 2019. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed services 
are 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 lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on April 3, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a CYP gene panel provided to the enrollee on August 17, 
2019. 
 
You asked the Plan to pay for the panel. You say that this should be paid for. The Plan denied your request. 
The Plan says the CYP gene panel is a single unit of service and the single code used to report the CYP gene 
panel is not covered. 
 
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare 
rules for coverage of the panel have not been met. Therefore, we decided that the Plan does not have to pay for 
a CYP gene panel provided to the enrollee on August 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office virtual visit (99213) on 
May 1, 2020. 
 
You asked the Plan to waive the copayment for a specialist office virtual visit. You say that the Plan's website 
indicated that your copayment would be $25. 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 $50 
copayment for consultation, diagnosis, and treatment by a specialist.  
 
You have been asked to pay a $50 copayment for a specialist office virtual visit. A specialist office virtual visit 
falls within the "Physician/Practitioner services, including doctor?s office visits" 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 a specialist office virtual visit (99213) on May 1, 2020.  
 
Your complaint about misleading information provided on the Plan's website is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for manual therapy (97140) provided January 15, 2020 to 
January 22, 2020. 
 
You asked the Plan to pay for manual Therapy. You say that the doctor did provide you with a corrected 
statement, which now also shows the third episode on 3/13/20. The CPT codes are included and the billing 
clerk wrote in the diagnostic codes. The Plan denied your request. The Plan says this service is not covered 
when billed by a chiropractor. 
 
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 plan must follow Medicare rules. Medicare rules say that this PPO plan will generally cover your medical 
care as long as the care you receive is considered medically necessary and you receive your care from a 
provider who is eligible to provide services under Original Medicare. As a member of the PPO plan you can 
receive your care from either a network provider or an out-of-network provider. 
 
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 manual therapy (97140) provided January 15, 2020 to January 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intellibed Split King Mattress System provided on 
December 29, 2019. 
 
You asked the Plan to pre-approve the Intellibed Split King Mattress System. You say that this is medically 
necessary. The Plan denied your request. The Plan says that they cannot pay a provider who is not eligible to 
participate in Medicare. 
 
The Plan must follow Medicare rules. The rules state that Medicare payment cannot be made to a supplier who 
is not enrolled in the Medicare Program. 
 
The purchase was not made with a supplier who is enrolled in the Medicare program. Therefore, we decided 
that the Plan does not have to pre-approve the Intellibed Split King Mattress System provided on December 29, 
2019.