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

We decided that the Plan does not have to pay for lab services (81401).

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services 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.

We find that CPT code 81401 is not supported in the medical record. Specifically, the records show the services were provided in the office setting (POS 11) while the claim form shows the specimen was taken in the laboratory setting (POS 81). The documentation does not clearly show the correct place of service. 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 lab services (81401).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SNF stay.

You asked the Plan to waive the copayment for the SNF stay. You say that you were not told that your current stay and prior stay were considered the same stay. You say you would like the benefit period to start on July 20, 2020. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $0 copayment per day for days 1-20 and a $178 copayment per day for days 21-100.

You have been asked to pay a $3,204 copayment for the SNF stay. The SNF stay falls within the "Skilled nursing facility (SNF) care" benefit category. See provided chart.

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 SNF stay.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a chiropractic office visit (99202) provided on July 24, 2020. 
 
You asked the Plan to pay for a chiropractic office visit. You say that you were told this would be covered 
because the chiropractor is in-network. 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 a chiropractic office visit (99202) provided on July 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral L3 to S1 RFA for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the covering LCD clearly limits the number of RFA injections to four RFA injections 
per session either 2 RFAs bilaterally or 4 RFAs unilaterally. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is a lack of documentation of physical exam findings, recent imaging and a lack of conservative 
therapy.  The request also exceeds the utilization limits of the LCD. 
 
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 pre-approve bilateral L3 to S1 RFA for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultrasound, laboratory services, practitioner services and 
injections provided on January 30, 2020. 
 
You asked the Plan to pay for the ultrasound, laboratory services, practitioner services and injections. The Plan 
denied your request. The Plan says the Plan requires utilization of network providers when possible and 
available, and requires authorization for certain services. No medical necessity for an out-of-network provider, 
such as an urgent or emergency situation, has been documented.   
 
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 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 to pay for an ultrasound, laboratory services, practitioner services and 
injections provided on January 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (81406, 81335, 81479) provided on May 
27, 2020. 
 
You asked the Plan to pay for laboratory services. You say that these services should be covered. The Plan 
denied your request. The Plan says these services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. To report a CGP service, test providers should 
use CPT code 81479 at this time, in addition to the approved DEX Z-Code for the test. 
 
We find that CPT codes 81406, 81335, and 81479 are not supported in the medical record. Specifically, the 
record indicates that the services at issue were a CGP service and should be reported with one 81479 code. 
Based on this information, we decided that Medicare rules for coverage of laboratory services have not been 
met. Therefore, we decided that the Plan does not have to pay for laboratory services (81406, 81335, 81479) 
provided on May 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a chiropractic office visit (99203) provided on May 18, 2020. 
 
You asked the Plan to pay for a chiropractic office visit. You say that you were told you could see this 
chiropractor. 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 a chiropractic office visit (99203) provided on May 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the family is upset and does not want the enrollee to 
return to the same level of care. You say that the enrollee is at risk of not regaining full function if they don't 
receive a higher level of nursing care. The Plan denied your request. The Plan says the guidelines for coverage 
of IRF care have not been met. 
 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for metabolic encephalopathy. The enrollee's medical conditions are stable. There are no medical 
needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The enrollee does 
not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record documents a need for physical and 
occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the continuous glucose monitor and supplies provided to the enrollee.

You asked the Plan to pay for the continuous glucose monitor and supplies. You say that the provided CGM and supplies were medically necessary. The Plan denied your request. The Plan says that the enrollee did not meet Medicare criteria for the CGM and supplies.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered reasonable and necessary for enrollees with diabetes who meet criteria referenced 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 pay for the continuous glucose monitor and supplies. Our reviewer says that the enrollee met Medicare criteria for the CGM and supplies. Our physician reviewer found the enrollee is with type 2 diabetes mellitus on levemir and novolog and victoza. She takes novolog 4 units with meals and an extra 4 units if blood glucose is greater than 170. The note states that the enrollee takes insulin if blood glucose is greater than 170 post meal and the enrollee checks blood glucose levels 2 hours post meal. Her fasting blood glucose levels are 42-287. She is checking blood glucose levels with libre 3-4x/day and a1c is 8.6. The enrollee has a distal right arm amputation and the libre makes it easier for her to check her blood glucose levels.

The enrollee is checking blood glucose levels pre and post meal and is adjusting insulin doses based on these blood glucose levels. She is taking 5 shots of insulin per day. In addition, she is physically limited by her right arm distal amputation so the libre is particularly helpful for her diabetes mellitus care and management.

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 continuous glucose monitor and supplies have been met. Therefore, we decided that the Plan has to pay for the continuous glucose monitor and supplies provided to the enrollee.

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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan (74177).

You asked the Plan to waive the copayment for a CT scan. You say that your responsibility should be lower. The Plan denied your request. The Plan says this processed correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 copayment for CT scans. 

You have been asked to pay a $325 copayment for a CT scan. 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 computed tomography (CT) scan (74177).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient office visits (99213)  x-ray, 
hips, bilateral (73521)  x-ray, hip, unilateral (73502) provided August 27, 2019 to February 4, 2020. 
 
You asked the Plan to waive the copayment for the office visits and diagnostic services. You say that all of 
these appointments were for post-surgical follow ups related to having a total hip replacement. You should not 
incur any responsibility for diagnostic testing which was required following surgery. The Plan denied your 
request. The Plan says the claim was processed and the correct copayment were applied per the Evidence of 
Coverage. 
 
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 per the 
2019 EOC $35 copay for x-rays $20 copay for specialist services and per the 2020 EOC $50 copay for x-rays 
and $30 copay for physician specialist services.  
 
You have been asked to pay $65 for the office visits and diagnostic services. The office visits and diagnostic 
services falls within the Physician/practitioner services including doctor's office visits and 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 waive the 
copayment for the outpatient office visits (99213)  x-ray, hips, bilateral (73521)  x-ray, hip, unilateral (73502) 
provided August 27, 2019 to February 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the outpatient surgery services rendered on 
September 14, 2020. 
 
You asked the Plan to waive the deductible for these services. You say that your deductible was already met. 
The Plan denied your request. The Plan says the deductible was 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 says that there is $1,000 yearly deductible for your covered medical services.  
 
The item or service you asked the Plan to waive the deductible for falls within the outpatient surgery benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $1,000 yearly 
deductible for your covered medical services. This cost sharing is a contractual obligation that had not been 
met at the time these services were received on September 14, 2020. Therefore, we decided that the Plan does 
not have to waive the deductible for the outpatient surgery services rendered on September 14, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the 
thorax (71250) provided on August 18, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $325 per 
day for Medicare-covered diagnostic radiology services. You pay $100 for an ultrasound.   
 
You have been asked to pay $131.90 for the diagnostic radiology service provided. This is the Plan allowed 
amount which is less than the applicable copayment for this service. 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 computed tomography (CT) scan of the thorax (71250) provided on August 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
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 based on the documentation provided, the health plan's denial should be upheld. You 
do not require the intensity of services provided at an IRF. Specifically, you are not shown to be able to 
perform fifteen hours per week of rehabilitative services with regular physician evaluation. Your care needs 
can be met 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the application of desensitizing medicament (D9910).

You asked the Plan to pay for this service. You say that you would like this covered. The Plan denied your request. The Plan says that this is not covered by the Plan.

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 among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the application of desensitizing medicament (D9910).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prefabricated post and core in addition to crown (D2954) 
provided on July 1, 2020. 
 
You asked the Plan to pay for the prefabricated post and core. You say that you feel the prefabricated post and 
core was necessary for the security of your tooth in the future. The Plan denied your request. The Plan says 
criteria coverage has not been met, and this procedure will not be covered. 
 
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 
among those covered under this benefit. The contract clearly states that a prefabricated post and core in 
addition to crown (D2954) must be performed together with a crown. The record does not show that a crown 
was provided at the time of this service. Therefore, we decided that the Plan does not have to pay for the 
prefabricated post and core in addition to crown (D2954) provided on July 1, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 and G0483 provided on April 
10, 2020. 
 
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 80307 and G0483 are not supported in the medical record. Specifically, the place of 
service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was 
obtained. The submitted claim form indicates that the specimen was obtained in a laboratory, place of service 
81; however, the submitted medical documentation and/or claim history indicates that the specimen was 
obtained in an office setting, place of service 11. Based on this information, we decided that Medicare rules for 
coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for 
the drug testing coded 80307 and G0483 provided on April 10, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the magnetic resonance imaging (MRI) 
scan of the lumbar spine (72148) provided on October 15, 2020. 
 
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to 
the service provided. 
 
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 20% 
coinsurance up to a maximum of $75 per day for Medicare-covered diagnostic radiology services.  
 
You have been asked to pay $54.63 (Plan allowed amount of $273.14 x 20% coinsurance) for the Medicare-
covered diagnostic radiology service provided. 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 
magnetic resonance imaging (MRI) scan of the lumbar spine (72148) provided on October 15, 2020.