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

 
We decided that the Plan does not have to pay for the positron emission tomography (PET) with concurrently 
acquired computed tomography (CT) provided April 17, 2020. 
 
You asked the Plan to pay for the PET with concurrently acquired CT. You say that the procedure was 
performed at the request of the referring doctor, as the enrollee's medical condition proved the medical 
necessity for the service. Please reconsider and reprocess for payment. The Plan denied your request. The Plan 
says this claim was not reported with an appropriate diagnosis code. 
 
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, PET procedures  performed to inform the subsequent treatment strategy of cancerous tumors 
(modifier  PS)  must be reported with an appropriate diagnosis. There are certain diagnosis codes that should be 
billed for these services. C34.91 (Malignant neoplasm of unspecified part of right bronchus or lung) is not 
listed as an acceptable diagnosis code. Based on this information, we decided that Medicare rules for coverage 
of the PET with concurrently acquired CT have not been met. Therefore, we decided that the Plan does not 
have to pay for the positron emission tomography (PET) with concurrently acquired computed tomography 
(CT) provided April 17, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81225, 81401, 81335, 81232, 
81479, 81479, 81479, 81479, 81479, 81479, 81226, 81479, 81479, 81479, 81355, 81230, 81231, 81291, 81240, 
81241, 81328, 81227 and 81406 provided on August 29, 2019. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 81225, 81401, 81335, 81232, 81479, 81479, 81479, 81479, 81479, 81479, 81226, 
81479, 81479, 81479, 81355, 81230, 81231, 81291, 81240, 81241, 81328, 81227 and 81406 is not supported in 
the medical record. Specifically, the CYP gene panel is a single unit of service and the single code used to 
report the CYP gene panel is not covered. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay 
for the laboratory services coded 81225, 81401, 81335, 81232, 81479, 81479, 81479, 81479, 81479, 81479, 
81226, 81479, 81479, 81479, 81355, 81230, 81231, 81291, 81240, 81241, 81328, 81227 and 81406 provided 
on August 29, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance provided on February 21, 2019 
and August 22, 2019. 
 
You asked the Plan to pay for the periodontal maintenance. You say that you thought this service was 
preventive because it was a cleaning. The Plan denied your request. The Plan says this service is not a covered 
benefit. The Plan also says that periodontal maintenance is not a preventative cleaning because it is considered 
a deep cleaning. 
 
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 
periodontal maintenance provided on February 21, 2019 and August 22, 2019.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for hospital observation services provided from 
June 7, 2020 to June 9, 2020. 
 
You asked the Plan to waive the copayment for hospital observation services. You say that you visited the 
hospital for the same issue previously and believe you should not have to pay twice. The Plan denied your 
request. The Plan says the copayment you are being charged is correct. 
 
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 a $750 deductible for after the deductible is met for outpatient hospital 
observation services.  
 
The hospital observation services you asked the Plan to waive the copayment for falls within the benefit 
category of outpatient hospital observation. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is a $750 deductible for after the deductible is met for outpatient hospital observation 
services. This cost sharing is a contractual obligation that had not been met at the time hospital observation 
services was received on June 7, 2020 to June 9, 2020. Therefore, $353.04 has been applied to meet your 
deductible. 
 
Since the $750 deductible was met, you have also been asked to pay a $125 copayment for hospital observation 
services, for a total of $478.04 ($353.04 + $125). 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 
hospital observation services provided from June 7, 2020 to June 9, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supplies provided during ambulance transport on January 
27, 2020. 
 
You asked the Plan to pay for the supplies. The Plan denied your request. The Plan says separate payment 
cannot be made for the supplies. 
 
The Plan must follow Medicare rules. Medicare rules say that payment for supplies are included under the 
ambulance benefit.  
 
We looked at the file and Medicare rules. Payment for the requested supplies is included under the ambulance 
benefit. The Plan has paid for the ambulance transportation. Based on this information, we decided that 
Medicare rules for coverage of the supplies have not been met. Therefore, we decided that the Plan does not 
have to pay for the supplies provided during ambulance transport on January 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the percutaneous lysis of epidural adhesions (62254). 
 
You asked the Plan to pay for the percutaneous lysis of epidural adhesions. You say that this should be paid 
based on the Medicare fee schedule. The Plan denied your request. The Plan says this is experimental. 
 
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 pay for the percutaneous lysis of epidural adhesions. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this procedure is considered experimental and investigational as there have 
only been anecdotal reports and case series published. 
 
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 percutaneous lysis of epidural adhesions have not been met. Therefore, we 
decided that the Plan does not have to pay for the percutaneous lysis of epidural adhesions (62254).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for knee orthosis and addition (L1851 and L2397) and 
neuromuscular stimulator (E0745) provided on March 21, 2020. 
 
You asked the Plan to pay for the knee orthosis, addition and neuromuscular stimulator. You say that you 
would like reconsideration because the documentation clearly shows medical necessity based on the doctor's 
review of the member. The Plan denied your request. The Plan says the records do not indicate if the telephonic 
interview was conducted by a physician or an employee of this provider. 
 
 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for knee orthosis and addition 
(L1851 and L2397) and neuromuscular stimulator (E0745) provided on March 21, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ultrasound elastography (76981) provided November 11, 
2019. 
 
You asked the Plan to pay for ultrasound elastography. You say that the records provided should support the 
necessity of the service in dispute. The Plan denied your request. The Plan says parenchymal elastography is 
not a covered benefit. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of ultrasound elastography have not been met. Therefore, we decided that the Plan does not have to 
pay for ultrasound elastography (76981) provided November 11, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a CYP gene panel provided to the enrollee on September 14, 
2019. 
 
You asked the Plan to pay for the servcies. You say that they have submitted other claims with the same codes 
(minus 1 or 2 codes) and those claims have paid. The Plan denied your request. The Plan says the CYP gene 
panel is a single unit of service, and the single code used to report the CYP gene panel is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare 
rules for coverage of the servcies have not been met. Therefore, we decided that the Plan does not have to pay 
for a CYP gene panel provided to the enrollee on September 14, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mammography and screening digital tomography 
provided on December 19, 2019. 
 
You asked the Plan to pay for the mammography and screening digital tomography. You say that because of 
your history your physician wants you to have mammography every 6 months. The Plan denied your request. 
The Plan says you exceeded limits set in the subscriber agreement. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The Plan only covers one screening mammography per calendar year. There is no physician order in the case 
file. Therefore, we decided that the Plan does not have to pay for the mammography and screening digital 
tomography provided on December 19, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the copayment for the arthrocentesis (20605) provided on 
January 7, 2020. 
 
You asked the Plan to adjust the copayment for this service. 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 $295 
copayment for Medicare-covered surgery or other services provided to you at hospital outpatient facilities and 
ambulatory surgical centers. 
 
You have been asked to pay a $243.22 copayment for the Medicare-covered surgery provided at an outpatient 
hospital facility. This is the Plan allowed amount which is less than the applicable copayment. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. The record shows that you 
initially paid $35 at the time of service, therefore, your remaining balance is $208.22. 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 adjust the copayment for the arthrocentesis (20605) provided on January 7, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services (99291) provided on January 27, 2020 
through January 28, 2020. 
 
You asked the Plan to pay for the critical care services. You say that you would like reconsideration based on 
the records submitted. 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. 
 
In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the record. Specifically, the record does not indicate that 30 
minutes of critical care services were rendered on the billed dates of service. Based on this information, we 
decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided 
that the Plan does not have to pay for critical care services (99291) provided on January 27, 2020 through 
January 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first intraoral periapical x-ray provided on April 13, 
2020. 
 
You asked the Plan to pay for the first intraoral periapical x-ray. You say that you were seen on an emergency 
basis due to severe tooth pain. The Plan denied your request. The Plan says this service is not 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. Therefore, we decided that the Plan does not have to pay for the first 
intraoral periapical x-ray provided on April 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Behavioral Health Inpatient services from March 19, 2020 to 
March 23, 2020. 
 
You asked the Plan to pay for Behavioral Health Inpatient services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the enrollee was stable and could have been treated at a 
lower level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 Behavioral Health services. Our reviewer 
says that the service was not reasonable and medically necessary. Our physician reviewer found based upon 
review the records provided it was not expected this enrollee would improve in a reasonable period of time as 
the enrollee did not have dangerousness to self or others, visual hallucinations or behaviors threatening acute 
safety. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute 
inpatient level of care rather than a lower level of care. The health plan's denial of inpatient psychiatric services 
appears appropriate. This enrollee was not a danger to self or others and was cooperative with care without any 
aggressive behaviors. It did not appear that active treatment was taking place. It did not appear that the services 
were reasonably expected to improve the enrollees condition or for the purpose of diagnosis. Based upon 
review the records provided for the admission of this enrollee did not meet criteria for acute inpatient mental 
health treatment.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Behavioral Health Inpatient services have not been met. Therefore, we decided 
that the Plan does not have to pay for Behavioral Health Inpatient services from March 19, 2020 to March 23, 
2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visits (99509) provided on January 1, 2019 through 
November 13, 2019. 
 
You asked the Plan to pay for the home visits. You say that you would like reconsideration because this service 
has been reimbursed in the past. The Plan denied your request. The Plan says CPT code 99509 has a status 
code of I and is not recognized under Medicare or the Plan. 
 
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 99509 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT 
code 99509 has a status indicator of I. This means that CPT code 99509 is not valid for Medicare purposes. 
Based on this information, we decided that Medicare rules for coverage of the home visits have not been met. 
Therefore, we decided that the Plan does not have to pay for home visits (99509) provided on January 1, 2019 
through November 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the maxillary interim partial denture (D5820) provided on 
May 13, 2020. 
 
You asked the Plan to pay for the maxillary interim partial denture. You say that your previous denture became 
unsafe to use. You also say that this is a medical claim, and not a dental claim. The Plan denied your request. 
The Plan says this service is not a covered benefit under your dental 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 
maxillary interim partial denture (D5820) provided on May 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wig you received on March 13, 2020. 
 
You asked the Plan to pay for the wig. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is non-covered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pay for the wig you received 
on March 13, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit (99348) provided on May 23, 2019. 
 
You asked the Plan to pay for the home visit. You say that you would like reconsideration because the services 
rendered were medically necessary. The Plan denied your request. The Plan says the billed code does not 
appropriately reflect the services provided by the resident nurse. 
 
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 99348 is home visit for the evaluation and management 
of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused 
interval history; An expanded problem focused examination; Medical decision making of low complexity. 
Counseling and/or coordination of care with other physicians, other qualified health care professionals, or 
agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. 
Usually, the presenting problem(s) are of low to moderate severity. Typically, 25 minutes are spent face-to-face 
with the patient and/or family.  
 
We find that CPT code 99348 is not supported in the record. Specifically, the billed code does not 
appropriately reflect the services provided by the resident nurse. A home visit cannot be billed by a physician 
unless the physician was actually present in the beneficiary's home. Based on this information, we decided that 
Medicare rules for coverage of the home visit have not been met. Therefore, we decided that the Plan does not 
have to pay for the home visit (99348) provided on May 23, 2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit (99337) rendered by the 
out of network (OON) provider on December 6, 2019. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the domiciliary or rest home visit (99337) rendered by the out of network (OON) provider on 
December 6, 2019.