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

 
We decided that the Plan does not have to pay for laboratory services (80307, G0483) provided January 3, 
2020. 
 
You asked the Plan to pay for laboratory services. You say that you would like reconsideration based on the 
medical records provided. The Plan denied your request. The Plan says there is no evidence of an established 
relationship between the enrollee and the ordering provider. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem. 
 
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services 
(80307, G0483) provided January 3, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the occupational therapy evaluation (97197) and therapeutic 
procedure (97112) provided on January 3, 2020 through January 28, 2020. 
 
You asked the Plan to pay for the therapy services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the documentation submitted does not support 
the service 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 97167 is occupational therapy evaluation, high 
complexity, requiring these components: An occupational profile and medical and therapy history, which 
includes review of medical and/or therapy records and extensive additional review of physical, cognitive, or 
psychosocial history related to current functional performance; An assessment(s) that identifies 5 or more 
performance deficits (ie, relating to physical, cognitive, or psychosocial skills) that result in activity limitations 
and/or participation restrictions; and Clinical decision making of high analytic complexity, which includes an 
analysis of the patient profile, analysis of data from comprehensive assessment(s), and consideration of 
multiple treatment options. Patient presents with comorbidities that affect occupational performance. 
Significant modification of tasks or assistance (eg, physical or verbal) with assessment(s) is necessary to enable 
patient to complete evaluation component. Typically, 60 minutes are spent face-to-face with the patient and/or 
family.  
 
The CPT Code Manual definition of code 97112 is therapeutic procedure, 1 or more areas, each 15 minutes; 
neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or 
proprioception for sitting and/or standing activities. 
 
We asked our coder 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 therapy services. Our reviewer says that CPT codes 
97167 and 97112 do not meet criteria for billing or reimbursement consideration. 
  
Our reviewer found the documentation does not include a high complexity evaluation, including the 
components required to verify this level of service has been performed. Additionally, the documentation does 
not include therapeutic procedure, 1 or more areas, each 15 minutes, neuromusclular reeducation of movement, 
balance, coordination, kinesthetic sense, posture and/or proprioception for sitting and/or standing activities was 
performed. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pay for the occupational therapy evaluation (97197) and therapeutic procedure (97112) 
provided on January 3, 2020 through January 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on January 6, 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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a
physician who has furnished a consultation or treats an enrollee for a specific medical problem.
The file does not contain documentation of an established relationship between the enrollee and the ordering
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this
testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing
rendered on January 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for any out-of-pocket expenses you feel you overpaid. 
 
You asked the Plan to reimburse you for amounts you feel you paid over your maximum out-of-pocket limits. 
You say that in 2019 you paid more than your maximum out-of-pocket amount. The Plan denied your request. 
The Plan says you accrued $1866.35 towards your in-network maximum out of pocket limit and $4338.62 
toward your combined maximum out-of-pocket limit. 
 
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 your in-network maximum out-of-pocket amount is $3000 and your combined 
maximum out-of-pocket amount is $4500. 
 
The item or service you asked the Plan to reimburse you for falls within the benefit category- understanding 
your out-of-pocket costs for covered services. The Plan has followed Medicare rules by clearly disclosing in 
the contract that your in-network maximum out-of-pocket amount is $3000 and your combined maximum out-
of-pocket amount is $4500. These out-of-pocket amounts are a contractual obligation that had not been met in 
2019. The record shows you did not pay over the maximums outlined in your 2019 Evidence of Coverage. 
Therefore, we decided that the Plan does not have to reimburse you for any out-of-pocket expenses you feel 
you overpaid.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services (D5120, D0150, D5110) provided from 
January 14, 2020 to January 24, 2020 by a provided who has opted out of Medicare. 
 
You asked the Plan to pay for dental services. You say that you were not informed this provider had opted out 
of Medicare. The Plan denied your request. The Plan says these services are not covered when provided by a 
provider who has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
dental services (D5120, D0150, D5110) provided from January 14, 2020 to January 24, 2020 by a provided 
who has opted out of Medicare.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adjunctive pre-diagnostic test (D0431) provided on 
March 9, 2020. 
 
You asked the Plan to pay for the adjunctive pre-diagnostic test (D0431). You say that the records show the 
need for the services rendered. 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 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 
adjunctive pre-diagnostic test (D0431) provided on March 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for diagnostic X-rays (77065) performed on 
November 7, 2018, November 12, 2019, and January 7, 2020; or for a physician specialist office visit (99203) 
on November 14, 2018; or to waive the deductible and copayment for a partial mastectomy (19301) performed 
on December 11, 2018. 
 
You asked the Plan to waive the copayment for X-rays and a specialist office visit and to waive the deductible 
and copayment for a partial mastectomy. You say that these charges are fraudulent or erroneous. The Plan 
denied your request. The Plan says the correct copayments and deductible 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 $35 
copayment for X-rays, a $35 copayment for specialist services, and, after you pay a $1,000 deductible, a $195 
copayment for outpatient hospital surgery in 2018; a $35 copayment for X-rays in 2019; and a $50 copayment 
for X-rays in 2020.  
 
You have been asked to pay a $35 copayment for X-rays performed in 2018 and 2019, a $50 copayment for X-
rays performed in 2020, a $35 copayment for a specialist office visit in 2018, and a $1,000 deductible and a 
$195 copayment for a partial mastectomy performed in 2018. 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 diagnostic 
X-rays (77065) performed on November 7, 2018, November 12, 2019, and January 7, 2020; or for a physician 
specialist office visit (99203) on November 14, 2018; or to waive the deductible and copayment for a partial 
mastectomy (19301) performed on December 11, 2018.  
 
Your complaint about misinterpretation and mishandling of your request by the Plan 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 30, 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 the testing is not covered. 
 
The Plan must follow Medicare rules. The rules say that testing to confirm that a urine specimen is 
unadulterated is an internal control process that is not separately reportable. 
 
We looked at the file and Medicare rules. The file shows that the tests at issue were urine specimens utilized for 
drug testing. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on 
January 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on August 15, 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 22214 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 22214 is osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; lumbar. We find that CPT code 22214 is not supported in the medical record. Specifically, the records show that lumbar osteotomy was performed with thoracic osteotomy, for which the appropriate code has already been processed. There is no documentation of a lumbar osteotomy of one vertebral segment. 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 surgical services rendered on August 15, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing provided on November 26, 2019. 
 
You asked the Plan to pay for the drug testing. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says the claims history does not show that there is an established relationship 
between the enrollee and the ordering provider. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the definitive drug 
testing provided on November 26, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (G0483, 80307, 80157, 80177, 80201, 
80162, 80159, and 80173) provided on December 19, 2019. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say for Medicare to consider coverage and payment for any 
item or service, the information submitted by the supplier or provider must corroborate the documentation in 
the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of laboratory services have not been met. The record did not include a physician order/lab requisition 
or medical records stating exactly what tests are to be performed. Therefore, we decided that the Plan does not 
have to pay for the laboratory services (G0483, 80307, 80157, 80177, 80201, 80162, 80159, and 80173) 
provided on December 19, 2019.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CPT code 99283 provided on February 12, 2020. 
 
You asked the Plan to pay for CPT code 99283. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says CPT code 99283 was not billed with an appropriate 
modifier. 
 
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 looked at the file and Medicare rules. The file shows that CPT code was 99283 was billed on the same day 
as a minor surgical procedure with CPT code G0168 without an appropriate modifier. Based on this 
information, we decided that Medicare rules for coverage of CPT code 99283 have not been met. Therefore, we 
decided that the Plan does not have to pay for CPT code 99283 provided on February 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics received on December 19, 2019. 
 
You asked the Plan to pay for the foot orthotics. You say that the orthotics received in March of 2019 should 
count against your 2018 benefit. The Plan denied your request. The Plan says you exhausted your 2019 benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you received orthotics in March of 2019 that count against your 2019 benefit. The orthotics 
provided in December 2019 are over your yearly limit. Therefore, we decided that the Plan does not have to 
pay for foot orthotics received on December 19, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the A1C testing provided on September 11, 2019. 
 
You asked the Plan to pay for the A1C testing. You say that this was billed correctly and should be covered. 
The Plan denied your request. The Plan says this claim was billed with a POS code of 11 but the record shows 
that this sample was taken in the home. As such, the home POS code should be reported. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing should be billed with the POS code of 
the setting in which the sample was taken. 
 
In this case, the record does not support the POS code 11, for the office setting. Therefore, we decided that the 
Plan does not have to pay for the A1C testing provided on September 11, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on January 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 there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing 
rendered on January 22, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on December 20, 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 there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing 
rendered on December 20, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab assays of carbamazepine, clozapine, digoxin, 
haloperidol, levetiracetam, and topiramate billed for date of service January 6, 2020. 
 
You asked the Plan to pay for the lab assays. You say that these tests are medically necessary. The Plan denied 
your request. The Plan says payment was approved for the urine drug testing; however, the other billed tests 
require a blood sample which was not taken. 
 
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 billed in this case are not supported. These codes are for testing of a sample of plasma, 
but there is no evidence that a blood sample was taken. Based on this information, we decided that Medicare 
rules for coverage of the lab assays have not been met. Therefore, we decided that the Plan does not have to 
pay for the lab assays of carbamazepine, clozapine, digoxin, haloperidol, levetiracetam, and topiramate billed 
for date of service January 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on April 9, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for chiropractic services. You say that you are appealing. The Plan denied your 
request. The Plan says the denial of payment for these services is correct, because this provider is out-of-
network with the Plan, authorization was not obtained, and medical records were not submitted to support 
coverage. 
 
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 medical services provided on April 9, 2020 by 
an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on December 2, 2019 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you would like reconsideration based on the 
medical records provided. The Plan denied your request. The Plan says services were provided out of network 
without prior authorization. 
 
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 laboratory services provided on December 2, 2019 
by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation, extraction and non-intravenous 
sedation provided on March 5, 2020. 
 
You asked the Plan to pay for the limited oral evaluation, extraction and non-intravenous sedation. You say that 
you had no idea the provider opted out of Medicare. You say that you should get reimbursed. The Plan denied 
your request. The Plan says payment cannot be issued for services performed by a provider who has opted out 
of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
the limited oral evaluation, extraction and non-intravenous sedation provided on March 5, 2020.