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

 
We decided that the Plan does not have to waive the copayment and coinsurance for the PET scan provided on 
February 27, 2020. 
 
You asked the Plan to waive the copayment and coinsurance for the PET scan. You say that you were not told 
there would be other charges besides the copayment you paid at the time of service. The Plan denied your 
request. The Plan says you were charged the copayment and coinsurance 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 $150 
copayment for PET scans and 20% coinsurance for Part B medications and contrast agents injected during the 
service, for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
You have been asked to pay a $150 copayment and 20% coinsurance for Part B medications and contrast 
agents injected during the service for the PET scan. The PET scan and injection fall within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment and coinsurance for the PET scan provided on February 27, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance supplies provided on March 18, 2020. 
 
You asked the Plan to pay for the ambulance supplies. You say that the transport was medically necessary. The 
Plan denied your request. The Plan says ambulance supplies are not separately payable. 
 
Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patient's health. The Plan follows the same rules. Medicare rules also say all services and supplies 
provided during an ambulance transport are covered under one billing code and each service and/or supply 
cannot be billed separately. 
 
We looked at the file and Medicare rules. Supplies are considered part of the general ambulance service and 
payment for them is included in the payment rate for the transport. Therefore, we decided that the Plan does not 
have to pay for the supplies provided on March 18, 2020.  
 
If the provider is billing you for charges beyond any applicable cost-sharing amounts, please contact the Plan 
directly.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on January 28, 2020. 
 
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 
does not include a valid 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 January 28, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy, 30 minutes with patient (CPT Code 90832) 
provided to the enrollee on February 24, 2020. 
 
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 the Medicare rules have not been met. 
 
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. We did not receive any medical 
records or any other additional information from the provider to process and pay the claim. Therefore, we 
decided that the Plan does not have to pay for psychotherapy, 30 minutes with patient (CPT Code 90832) 
provided to the enrollee on February 24, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing provided on January 30, 2020. 
 
You asked the Plan to pay for the drug testing. The Plan denied your request. The Plan says the documentation 
did not contain evidence of a relationship with the ordering physician. 
 
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. 
 
We looked at the file and Medicare rules. 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 Medicare rules for coverage have not been met. Therefore, we decided that the Plan 
does not have to pay for the definitive drug testing provided on January 30, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on December 16, 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 85025 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 85025 is blood count; complete (CBC), automated (Hgb, 
Hct, RBC, WBC and platelet count) and automated differential WBC count. 
 
We find that CPT code 85025 is not supported in the medical record. Specifically, the records do not show that 
a complete blood count was performed for the billed date of service. 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 laboratory services rendered on December 16, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on January 24, 
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 according to the claims data available at the time of the review, the plan was unable to discover 
any evidence of an established relationship between the member and the ordering physician. 
 
The Plan must follow Medicare rules. 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 drug testing services 
provided to the enrollee on January 24, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on December 5, 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 
does not include a valid 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 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the inversion table purchased on January 19, 2020. 
 
You asked the Plan to reimburse you for the inversion table. You say that you were told an inversion table is a 
covered item and you had a prescription for one. The Plan denied your request. The Plan says medical records 
were requested from your physician but not received. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. There is no evidence that you are nonambulatory. Based on this 
information, we decided that Medicare rules for coverage of the inversion table have not been met. Therefore, 
we decided that the Plan does not have to reimburse you for the inversion table purchased on January 19, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing provided on March 5, 2020. 
 
You asked the Plan to pay for the drug testing. You say that the proper code was billed for the services 
rendered. The Plan denied your request. The Plan says the billed code 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 definitive drug testing of 22 or more drug 
classes. We find that CPT code G0483 is not supported in the medical record. There were insufficient records 
that show the tests were needed to identify specific substances that were inadequately detected by a 
presumptive drug test. There is no evidence that shows the test was individualized to identify 22 or more 
specific non-prescribed medications or illicit substances. The records provided do not document concerns 
based on clinical review and judgement. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for the definitive drug 
testing provided on March 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nail debridement rendered on January 3, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 11721 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 11721 and 11055. Code 11721 is a column II code with a 
modifier indicator of 1 when billed with column I code 11055. Code 11721 was not billed with an appropriate 
modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the nail 
debridement rendered on January 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite (D2393) provided on March 2, 
2020. 
 
You asked the Plan to pay for the resin-based composite (D2393). You say that you received pre-approval for 
this. You say that you are appealing the denial for $220. 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 resin-
based composite (D2393) provided on March 2, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the small intestine x-ray rendered on March 14, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 74248 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 74248 is radiologic small intestine follow-through study, 
including multiple serial images (List separately in addition to code for primary procedure for upper GI 
radiologic examination). 
 
We find that CPT code 74248 is not supported in the medical record. Specifically, this is an add-on code that 
was not billed with a required primary procedure code. 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 small intestine x-ray rendered on March 14, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 29, 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 29, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance supplies provided on March 17, 2020. 
 
You asked the Plan to pay for ambulance supplies. You say that the only transportation available to you was by 
ambulance. The Plan denied your request. The Plan says the denial of payment for these supplies is correct, 
because ambulance supplies are included in the payment for ambulance transportation and cannot be separately 
paid. 
 
The Plan must follow Medicare rules. Medicare rules say that ambulance supplies are included in the payment 
for ambulance transportation and are not separately payable.  
 
We looked at the file and Medicare rules. The Plan has paid for the ambulance transportation charges, however 
the charges for supplies cannot be paid separately because according to Medicare rules they are included in the 
transportation charges. Therefore, we decided that the Plan does not have to pay for ambulance supplies 
provided on March 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an EKG provided by a participating 
provider on April 15, 2020. 
 
You asked the Plan to waive the copayment for an EKG. You say that you do not agree with this copayment. 
The Plan denied your request. The Plan says the correct copayment has been 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 $45 
copayment for outpatient diagnostic tests/specialty physician outpatient diagnostic tests.  
 
You have been asked to pay a $45 copayment for an EKG. The correct copayment has been applied to the 
services that were provided. An EKG falls within the outpatient diagnostic tests/specialty physician outpatient 
diagnostic tests 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 EKG provided by a 
participating provider on April 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyeglasses (V2797, V2020, V2781) provided May 28, 2020. 
 
You asked the Plan to pay for the eyeglasses. You say that the eyeglasses should be covered. The Plan denied 
your request. The Plan says the plan paid the claim according to your vision benefit. 
 
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.  
 
We looked at the file and the Plan's rules. The total amount exceeds the $150 allowance for eyeglasses the plan 
provides. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not 
been met. Therefore, we decided that the Plan does not have to pay for eyeglasses (V2797, V2020, V2781) 
provided May 28, 2020 beyond the amount already paid.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room services (99284) 
provided on April 30, 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 a $65 
copayment for each emergency room visit.  
 
You have been asked to pay a $65 copayment for the emergency room services 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 copayment for the emergency room services (99284) provided on April 30, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency care and self-administered drugs provided on 
December 2, 2019. 
 
You asked the Plan to pay for emergency care and self-administered drugs. You say that you dispute these 
charges. The Plan denied your request. The Plan says the copayment amount you are being charged is correct. 
The Plan also says that the denial of payment for self-administered drugs is correct, because these drugs are not 
covered by the Plan. 
 
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 $100 
copayment for emergency care visit. The Plan is also not responsible for the payment of self-administered 
drugs. The denied amount for self-administered drugs is $1. 
 
You have been asked to pay $100 copayment for emergency care. Emergency care 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. 
The Plan is also not responsible for payment for self-administered drugs. Therefore, we decided that the Plan 
does not have to pay for emergency care and self-administered drugs provided on December 2, 2019.  
 
Benefits for emergency care and self-administered drugs 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on November 25, 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 
does not include a valid 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 November 25, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on December 3, 2019. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed services 
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. 
 
The documentation shows that presumptive and definitive drug testing was provided. We looked at the file and 
the rules. The documentation does not show the testing was individualized to identify specific non-prescribed 
medications or illicit substances. The records provided do not document concerns based on clinical review and 
judgement. The testing is not covered for screening purposes.  
 
The documentation also shows that Carbamazepine and Levetiracetam (CPT codes 80157 and 80177) were 
provided. We find that CPT codes are not supported in the medical record. This testing is performed on blood 
samples. The documentation does not indicate that a blood sample was provided for the enrollee. 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 3, 2019.