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

We decided that the Plan has to pay for drug testing services (HCPCS G0480) provided to the enrollee on
February 12, 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 that Healthcare Common Procedure Coding System (HCPCS) code G0480 remains 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
HCPCS code G0480 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 matrixmatched
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; 1-7 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 there is a
form in the case file where the provider acknowledges the appropriateness of the test, and the codes in
question.
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 G0480) provided to the enrollee on February 12, 2020.
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 copayment for the office visit on January 24, 2020.
You asked the Plan to waive the copayment for the office visit. You say that you have been charged the correct
cost sharing amount. The Plan denied your request.
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 $10
copayment for a primary care physician.
You have been asked to pay a $10 copayment for the office visit. The office visit falls within the "Physician/
Practitioner services, including doctor's office visits" benefit category. The medical record shows the provider
also addressed the enrollee's conditions that are not included in the preventive visit.
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 the office visit provided on January 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the home oxygen concentrator provided
from April 25, 2016 to April 25, 2020.
You asked the Plan to waive the coinsurance for the home oxygen concentrator. You say that you returned the
portable oxygen concentrator. The Plan denied your request. The Plan says the coinsurance is still due for the
home oxygen concentrator that you still use.
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 20%
coinsurance for Durable Medical Equipment.
You have been asked to pay 20% coinsurance for the home oxygen concentrator. The oxygen concentrator falls
within the Durable Medical Equipment 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 coinsurance
for the home oxygen concentrator provided from April 25, 2016 to April 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on
January 9, 2019 by an OON provider.
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you understand that
this treating provider is OON. You also say that you will not switch to another provider because this office is
familiar with your fears and you are comfortable with this provider. The Plan denied your request. The Plan
says this provider is not a Plan provider. The Plan also says that no benefits are available for procedures
performed by OON providers or outside of the providers contracted period.
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, the requested items or services are not
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodic
oral evaluation and prophylaxis provided on January 9, 2019 by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested LTACH care is not considered medically reasonable and necessary in this case.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. All medically necessary care is being provided in the current acute care setting. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The health plan has approved ongoing care in the current acute care setting. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the services (CPT 14301, CPT 19316) provided on November 14,
2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that 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 14301 is "Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm". The CPT
Code Manual definition of code 19316 is "Mastopexy".
We asked our coding 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 use
of CPT codes 14301 and 19316 is not supported by the records provided. Our coding reviewer found that the
additional information submitted contains pathology confirming appropriate lumpectomy specimen size to
qualify CPT 14301 as a valid procedure performed on November 14, 2019. This along with the documentation
provided in the physician's operative note verifies this procedure was performed. Additionally, the operative
note in the enrollee's record documents that a donut mastopexy was performed. The detail of the procedure in
the operative note adequately describes CPT 19316 based on this description.
We looked at this coder'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
the services (CPT 14301, CPT 19316) provided on November 14, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal maintenance provided on December 20, 2019.
You asked the Plan to pay for periodontal maintenance. You say that you weren't satisfied with regular
cleanings. You say that you should be reimbursed because periodontal maintenance is a cleaning. The Plan
denied your request. The Plan says the service is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the periodontal maintenance is not
considered a preventive cleaning covered under this benefit. Therefore, we decided that the Plan does not have
to pay for periodontal maintenance provided on December 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bi-level respiratory assist device without back-up rate
(BiPAP) and heated humidifier for the enrollee.
You asked the Plan to pre-approve a BiPAP and humidifier. You say that these items are medically necessary.
The Plan denied your request. The Plan says that the enrollee has not had an arterial blood gas completed.
The Plan must follow Medicare rules. Medicare rules say that a BiPAP is covered if the enrollee meets the
above criteria.
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 a BiPAP and humidifier. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. The
enrollee's home sleep test showed an AHI and RDI of 10.6events/hr with 24 total events. There is no evidence
that the enrollee has hypertension, ischemic heart disease or a prior stroke. There is no evidence that the
enrollee has received instruction on the use of the E0470 device. There is no evidence that the enrollee has tried
and failed using an E0601 device. Our physician reviewer found that the enrollee's condition does not meet
Medicare criteria for a BiPAP and humidifier.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a BiPAP and humidifier have not been met. Therefore, we decided that the Plan
does not have to pre-approve a bi-level respiratory assist device without back-up rate (BiPAP) and heated
humidifier for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for deluxe frame (V2025) and refraction services (92015).
You asked the Plan to pay for the vision services. You say that there are no in-network providers within 10
miles of your residence. The Plan denied your request. The Plan says enrollee's must receive their vision
services from an in-network provider. The plan has also confirmed and provided a list of in-network providers
within 40 miles.
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 these services when rendered by an in-network provider.
We looked at the file and the Plan's rules. Vision services must be provided by an in-network provider. Based
on this information, we decided that the Plan's rules for coverage of the vision services have not been met.
Therefore, we decided that the Plan does not have to pay for deluxe frame (V2025) and refraction services
(92015).
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 March 11, 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 testing requires the use of CPT 81479.
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 services 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 March 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network
provider on February 6, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.
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 services at issue in this appeal. The Plan did not pre-approve the services at
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that
the Plan does not have
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ophthalmological services, medical
examination and evaluation (92004) provided February 18, 2020.
You asked the Plan to waive the copayment for vision services. You say that after your annual routine eye
exam you received a bill for $30 after paying $15 and you feel this copay should be waived or changed. You
have diabetes so you need annual exams. The Plan denied your request. The Plan says the copayment was
applied correctly as the enrollee had a diabetic eye exam and received a diagnosis and advice for a condition
during the exam.
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 $45 for
each Medicare covered outpatient visit for services to diagnose and/or treat a disease or condition of the eye.
You have been asked to pay $45 for the vision services. The vision services fall within the vision 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 ophthalmological services, medical
examination and evaluation (92004) provided February 18, 2020.
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, as the enrollee is not
making sufficient progress at the outpatient level of care. The Plan denied your request. The Plan says the care
can be safely received in other settings.
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 enrollee does not require the intensity of services provided at an IRF.
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular
physician evaluation. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR, outpatient
rehabilitation, HHS).
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the services are medically necessary. The
Plan denied your request. The Plan says coverage criteria has 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 pre-approve the SNF services. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found as a practical matter, this enrollee
does not require the necessary services daily, on an inpatient basis, in a skilled nursing facility setting. Services
can be provided at a lower level of care.
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 SNF services have not been met. Therefore, we decided that the Plan does
not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chemotherapy treatment with fluorouracil, leucovorin
calcium, oxaliplatin, and bevacizumab.
You asked the Plan to pre-approve the requested chemotherapy. You say that the enrollee is in a clinical trial
for this treatment and the plan should provide coverage. The Plan denied your request. The Plan says services
provided in a clinical trial should be paid by the Original Medicare contractor and not the health plan.
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in
Original Medicare and the plan cost-sharing for the same services.
In this case, you asked the Plan to pre-approve the requested chemotherapy as part of a clinical trial. The Plan
does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does
not have to pre-approve chemotherapy treatment with fluorouracil, leucovorin calcium, oxaliplatin, and
bevacizumab.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the BLS non-emergency ambulance (A0428) and ground
mileage (A0425) provided January 30, 2020.
You asked the Plan to pay for the ambulance services. You say that you live in a long term care facility and is
bed ridden. You have no control who is called for transport. You needed dental care for a broken tooth and the
only way to transport you was by ambulance. The Plan denied your request. The Plan says transportation to a
doctor's office is not covered.
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when
they meet certain origin and destination requirements. A doctor's office is not a covered destination.
The services you have asked the Plan to pay for are ambulance transport services to a doctor's office.
Therefore, we decided that the Plan does not have to pay for the BLS non-emergency ambulance (A0428) and
ground mileage (A0425) provided January 30, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion supplies provided from January 10, 2020
to January 16, 2020.
You asked the Plan to pay for the home infusion supplies. You say that the Plan should pay this claim. The
Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and
the Proof of Delivery did not include details to corroborate the Delivery Ticket.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket
does not have the tracking number on it and the Proof of Delivery does not have a description of the items
delivered. The record shows that the Plan made several attempts to obtain the necessary documentation without
success. Therefore, we decided that the Plan does not have to pay for the home infusion supplies provided from
January 10, 2020 to January 16, 2020.