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

 
We decided that the Plan does not have to pay for the laboratory testing coded 80157, 80159, 80162, 80173, 
80177, 80201, and G0483 provided on January 16, 2020. 
 
You asked the Plan to pay for the laboratory 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 80157, 80159, 80162, 80173, 80177, 80201, and G0483 are not supported in the 
medical record. Specifically, the submitted documentation does not indicate an order for the testing of at least 
22 drug classes. Therefore, code G0483 cannot be verified. The documentation submitted did not 
support that Carbamazepine; free testing was performed. Blood specimen collection is by venipuncture; 
however, the lab requisition states a urine specimen was collected; therefore, code 80157 cannot be verified. 
The documentation submitted did not support that Levetiracetam testing was performed. Blood specimen 
collection is by venipuncture; however, the lab requisition states a urine specimen was collected; therefore, 
code 80177 cannot be verified. The documentation submitted did not support that Topiramate testing was 
performed. Blood specimen collection is by venipuncture; however, the lab requisition states a urine specimen 
was collected; therefore, code 80201 cannot be verified. The documentation submitted did not support that 
Digoxin; total testing was performed. Blood specimen collection is by venipuncture; however, the lab 
requisition states a urine specimen was collected; therefore, code 80162 cannot be verified. The documentation 
submitted did not support that Clozapine testing was performed. Blood specimen collection is by venipuncture; 
however, the lab requisition states a urine specimen was collected; therefore, code 80159 cannot be verified. 
The documentation submitted did not support that Haloperidol testing was performed. Blood specimen 
collection is by venipuncture; however, the lab requisition states a urine specimen was collected; therefore, 
code 80173 cannot be verified. 
 
 
Based on this information, we decided that Medicare rules for coverage of the laboratory testing have not been 
met. Therefore, we decided that the Plan does not have to pay for the laboratory testing coded 80157, 80159, 
80162, 80173, 80177, 80201, and G0483 provided on January 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vascular surgery services provided on February 27, 2020 
billed with codes 37223-LT-XE-GC and 35355-LT-XE-GC. 
 
You asked the Plan to pay for the billed services. You say that this is correctly coded and should be paid. The 
Plan denied your request. The Plan says all codes were approved aside from codes 37223 and 35355 which are 
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. 
 
We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the billed services. Our reviewer says that 
these two codes are not supported by the medical records. Our coding reviewer found the enrollee is a male 
who received services on February 27, 2020 for Common Procedural Terminology (CPT) 37223 - 
Revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac vessel; with 
transluminal stent placement(s), includes angioplasty within the same vessel, when performed (List separately 
in addition to code for primary procedure) and Common Procedural Terminology (CPT) 35355 
- Thromboendarterectomy, including patch graft, if performed; iliofemoral.  
 
Documentation submitted was reviewed and criteria for these codes are not met. For CPT 37223, the operative 
report documents treating vessels in one vascular family.  Documentation does not support additional vessels 
treated; therefore, this code cannot be verified. The report also does not verify that a common femoral 
endarterectomy 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 billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for the vascular surgery services provided on February 27, 2020 billed with codes 37223-LT-
XE-GC and 35355-LT-XE-GC.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on February 15, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that the medics said it was not an emergency 
and you thought you were saving money. The Plan denied your request. The Plan says these services are not a 
covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on February 15, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on February 15, 
2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the copayment for the MRI of the brain (70551) and the MRI 
of the cervical spine (72141) provided on February 14, 2020. 
 
You asked the Plan to adjust 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 services 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 $110 
copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a 
physician?s office or freestanding facility.  
 
You have been asked to pay $220 ($110 copayment x 2) for the Medicare-covered radiological diagnostic 
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 adjust the copayment for the MRI of the brain (70551) and 
the MRI of the cervical spine (72141) provided on February 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary new patient and laboratory services provided 
on February 15, 2020 to March 4, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for domiciliary new patient and laboratory services. You say that because the 
assisted living facility has established relationships with providers who come to the facility, you did have an 
option to get an in-network provider. The Plan denied your request. The Plan says services must be obtained by 
in-network providers unless prior authorization was obtained. 
 
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 domiciliary new patient and laboratory 
services provided on February 15, 2020 to March 4, 2020 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) care 
provided from April 3, 2020, through May 17, 2020. 
 
You asked the Plan to waive the copayment for the SNF care. You say that you feel you should not be 
responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied 
your request. The Plan says you received SNF care on the dates of service at issue in this appeal. The Plan says 
that the correct cost share has applied per your contract with 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 a $0 
copayment per day for days 1-20 and a $178 copayment per day for days 21-100 for Skilled nursing facility 
(SNF) care.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received SNF care from 
April 3, 2020, through May 17, 2020. You have been asked to pay a $0 copayment per day for days 1-20, a 
$178 copayment per day for days 21-29, totaling $1424, and a $178 copayment per day for days 30-45, totaling 
$2209.16, which is less than the contracted total amount of $2848 due to you meeting your out of pocket 
maximum of $6700 for the 2020 benefit year. The SNF care falls within the Skilled nursing facility (SNF) care 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) 
care provided from April 3, 2020, through May 17, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Vitamin D assay rendered on June 1, 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 screening tests are not covered. 
 
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 test at issue in this appeal, a Vitamin D assay, was requested solely for screening purposes. Medicare does 
not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for 
the Vitamin D assay rendered on June 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the eye exam you had on July 8, 2020. 
 
You asked the Plan to waive the copayment. The Plan denied your request. The Plan says you are responsible 
for the copayment. 
 
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 $50 
copayment for an eye exam to diagnose and treat diseases and conditions of the eye.  
 
Review of the file shows that you had an eye exam on July 8, 2020. You have been asked to pay a $50 
copayment for the eye exam. The eye exam falls within the vision care benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for the eye exam you had on July 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for orthoses (L1851, L2385, L2397) provided April 8, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the items 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. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery. The delivery ticket provided does not include an itemized 
invoice or statement to confirm what items were delivered. The record shows that the Plan made several 
attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not 
have to pay for orthoses (L1851, L2385, L2397) provided April 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 6 extractions (D7140) provided on May 29, 2020 by the 
out of network provider. 
 
You asked the Plan to pay for the 6 extractions. You say that you were advised you would receive 45% of the 
cost. The Plan denied your request. The Plan says 2 extractions are covered per plan year. The Plan says that 
when the extractions are received out of network there is a 55% coinsurance that apples. The Plan also says that 
 
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 and 2 extractions are covered per 
calendar year, the frequency limit has been exceeded. The record shows that the Plan paid for an extraction that 
you received on April 22, 2020 and 1 extraction that you received on the date of service in this case. Therefore, 
we decided that the Plan does not have to pay for the 6 extractions (D7140) provided on May 29, 2020 by the 
out of network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on January 7, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says insufficient medical records were submitted to show this testing was medically 
necessary. 
 
Medicare rules say that providers must produce medical records showing why the lab services provided were 
medically necessary. In this case, there were insufficient records provided to show the results of this testing 
would be used to determine a diagnosis or determine a treatment strategy for disease or illness present in the 
enrollee at the time of service. This testing is not covered for screening purposes. Medicare coverage criteria 
are not met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee 
on January 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lower extremity orthotic addition with code L2385 
provided on April 12, 2020. 
 
You asked the Plan to pay for orthotic item. You say that you are appealing with records. The Plan denied your 
request. The Plan says the denial of payment for this item is correct, because the documentation submitted does 
not include proof of delivery for this specific item. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider must submit to the Plan sufficient 
information to determine whether payment is due for a claim. The information submitted by the provider must 
corroborate the medical record and confirm that coverage criteria have been met.  
 
We looked at the file and Medicare rules. The documentation submitted does not include proof of delivery for 
this specific item. The Plan requested this information, but it was not provided. Without proof of delivery, you 
have not furnished sufficient information to justify payment of the specific code L2385 billed on this claim. 
Based on this information, we decided that Medicare rules for coverage of orthotic item have not been met. 
Therefore, we decided that the Plan does not have to pay for a lower extremity orthotic addition with code 
L2385 provided on April 12, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing rendered on April 5, 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 services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that next generation sequencing is covered when 
specific criteria are met. 
 
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 these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee has a diagnosis of stave IV 
non-small cell lung cancer. A biopsy of a neck lymph node was supportive of squamous cell carcinoma. 
Documentation regarding previous testing and whether the enrollee has decided to seek further cancer 
treatment (e.g., therapeutic chemotherapy) is not available in the case file. The documentation does not support 
that the testing was reasonable and medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. 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 testing rendered on April 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided on March 31, 
2020. 
 
You asked the Plan to pay for the lumbar-sacral orthosis. You say that the durable medical equipment is 
medically necessary. The Plan denied your request. The Plan says the documentation submitted did not include 
an itemized shipping/billing invoice to indicate the supplies, or proof of delivery. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery. Specifically, the date of service billed does not match the 
proof of delivery documentation. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral 
orthosis (L0650) provided on March 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyeglasses (V2020, V2750, V2304) provided November 12, 
2019. 
 
You asked the Plan to pay for the eyeglasses. You say that you purchased eyeglasses in the past and they were 
covered. The Plan denied your request. The Plan says you are not enrolled in the optional eyewear coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The services you asked the Plan to pay for are considered routine vision services or eyewear. The record shows 
you have not enrolled in the plan's optional vision coverage. Therefore, we decided that the Plan does not have 
to pay for eyeglasses (V2020, V2750, V2304) provided November 12, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlab services provided to the enrollee on June 27, 2020 and billed under code 81542.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plandenied your request. The Plan says Medicare coverage criteria are not met. The Plan must follow Medicare rules. Medicare has specific coverage criteria for this testing. Based on the medical records provided, the enrollee does not meet those criteria. Therefore, we decided that the Plan does not have to pay forlab services provided to the enrollee on June 27, 2020 and billed under code 81542.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the negative pressure wound therapy 
electrical pump (E2402RR) provided on January 30, 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 durable medical equipment 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 20% of 
the Plan allowed amount for in-network Medicare-covered durable medical equipment. 
 
You have been asked to pay $258.63 ($1,293.15 Plan allowed amount x 20% coinsurance) for the durable 
medical equipment 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 negative pressure 
wound therapy electrical pump (E2402RR) provided on January 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nasal surgery (30999) and two gastrointestinal tube 
insertions (44500) provided on April 1, 2020. 
 
You asked the Plan to pay for nasal surgery and two gastrointestinal tube insertions. You say that this should be 
covered. The Plan denied your request. The Plan says the documentation does not support these services. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that the provider, supplier, or beneficiary, as appropriate, must 
furnish to the intermediary or carrier sufficient information to determine whether payment is due and the 
amount of payment. 
 
We looked at the file and Medicare rules. The submitted medical records do not indicate why the procedures at 
issue were performed. Without this information, medical necessity cannot be established. Based on this 
information, we decided that Medicare rules for coverage of nasal surgery and two gastrointestinal tube 
insertions have not been met. Therefore, we decided that the Plan does not have to pay for nasal surgery 
(30999) and two gastrointestinal tube insertions (44500) provided on April 1, 2020.