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

 
We decided that the Plan does not have to waive the coinsurance for the air ambulance transport service 
(A0431) and the air ambulance mileage (A0436) provided on March 25, 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 was applied correctly to the 
service provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for out of network, emergent air ambulance services provided.   
 
You have been asked to pay $1,416.97 ($7,084.85 allowed amount x 20% coinsurance) for the out of network, 
emergent air ambulance service provided. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the  
air ambulance transport service (A0431) and the air ambulance mileage (A0436) provided on March 25, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on December 20, 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 does not 
support that this testing was ordered by the enrollee's treating physician. 
 
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. The rules also say that lab tests must be ordered by the 
enrollee's treating physician. 
 
We looked at the file and Medicare rules. The documentation submitted does not support that these tests were 
ordered by the enrollee's treating physician. Therefore, 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 20, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on November 25, 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 codes 80201, 80162, 80159, and 80173 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. 
 
In this case, the CPT Code Manual definition of code 80201 is assay of topiramate. The definition of code 
80162 is assay of digoxin, total. The definition of code 80159 is clozapine drug assay. The definition of code 
80173 is assay of haloperidol. 
 
We find that CPT codes 80201, 80162, 80159, and 80173 are not supported in the medical record. Specifically, 
the documentation supports that urine testing was performed; therefore, these codes for blood testing are not 
supported. 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 
November 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of an ambulatory external infusion pump. 
 
You asked the Plan to pre-approve infusion pump. You say that you feel that this is medically necessary. The 
Plan denied your request. The Plan says the denial of authorization for this item is correct, because you do not 
meet the Medicare criteria for this item. 
 
The Plan follows Medicare rules. Medicare rules say that external infusion pumps may be covered for enrollees 
who meet certain clinical criteria. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve infusion pump. Our reviewer says that 
you do not meet the Medicare criteria for use of this external infusion pump. Our physician reviewer found 
Medicare requires a low C-peptide level or auto-antibody positivity which are not shown. In order to use an 
external infusion pump successfully, patients are taught to count dietary carbohydrates (carbs) as this is 
required to enter the correct carb content at meals so the pump can deliver the appropriate amount of insulin. 
Currently it is not shown that you have the skills to use the requested pump and there is not evidence that your 
medications are not working for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of infusion pump have not been met. Therefore, we decided that the Plan does not 
have to pre-approve use of an ambulatory external infusion pump.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is ready to go to inpatient rehab to get 
back to baseline level of activity. The Plan denied your request. The Plan says you don't meet the requirements 
for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that IRF level of therapies are not required given the enrollee's current level of 
function. Our reviewer says that the enrollee's rehab needs can be met in a lower intensity setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 20, 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 laboratory services 
rendered on January 20, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sleep studies (95810, 95811). 
 
You asked the Plan to pre-approve sleep studies. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that follow-up polysomnography or HST is not routinely 
indicated for patients treated with CPAP whose symptoms continue to be resolved with CPAP 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 pre-approve sleep studies. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found you do not meet the criteria for a repeat 
sleep study. Based on the notes provided, you have not lost significant amounts of weight or showed signs or 
symptoms suggestive of the current CPAP device and mask not being effective. A second opinion can still be 
obtained showing the results of the recent sleep study rather than repeating the test itself. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sleep studies have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sleep studies (95810, 95811).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance transport (A0425, A0398, 
A0427) provided January 23, 2020. 
 
You asked the Plan to waive the copayment for the ambulance transport. You say that the copayment should be 
waived. The Plan denied your request. The Plan says the correct copayment was 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 $150 
copayment for Ambulance Services.  
 
You have been asked to pay a $150 copayment for the ambulance transport. The ambulance transport falls 
within the Ambulance Services 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 ambulance transport (A0425, A0398, A0427) provided January 23, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing provided on January 13, 2020. 
 
You asked the Plan to pay for the testing services. 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. 
 
In this case, the CPT Code Manual definition of code G0481 is definitive drug testing of 8-14 drug classes. We 
find that CPT code G0481 is not supported in the medical record. 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 13, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab service provided on November 26, 2019. 
 
You asked the Plan to pay for the lab service. The Plan denied your request. The Plan says the billed service 
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 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. 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 lab service provided on 
November 26, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on February 17, 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 the services are not covered when they are provided out-of-network. 
 
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 lab services provided to the enrollee on February 
17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CPAP machine. 
 
You asked the Plan to pre-approve a CPAP machine. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria 
for a CPAP machine. 
 
The Plan must follow Medicare rules. Medicare rules say that certain criteria must be met for coverage of a 
CPAP machine.  
 
 
 
 
 
 
 
 
 
 
We looked at the file and Medicare rules. Medicare rules say that a sleepy study must be performed in order to 
determine if the enrollee meets Medicare criteria for a CPAP machine. The file does not show that the enrollee 
has had a recent sleep study. Based on this information, we decided that Medicare rules for coverage of a 
CPAP machine have not been met. Therefore, we decided that the Plan does not have to pre-approve a CPAP 
machine.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extraction, erupted tooth requiring removal of bone 
and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated, tooth #4 (D7210), for 
the enrollee. 
 
You asked the Plan to pre-approve the dental services. You say that you are requesting review of denial of 
services. The Plan denied your request. The Plan says the documentation submitted does not support the code 
requested. 
 
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. The Plan covers the dental 
services when the services are medically necessary and reasonable.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the dental services. Our physician 
reviewer found the request is for a surgical extraction of tooth #4. Tooth #4 presents with notable caries on the 
distal of the tooth, which does weaken the remaining structure.  
There is a substantial amount of bone present, and it is possible there might be complication with removal of 
the tooth using standard techniques, however this is not destined to occur and would be addressed at the time of 
removal. The Plan provides criteria as to extractions " Appropriate radiographs showing clearly the adjacent 
and opposing teeth should be submitted for authorization review: bitewings, periapicals or panorex. Treatment 
rendered under emergency conditions, when authorization is not possible, will still require that appropriate 
radiographs showing clearly the adjacent and opposing teeth be submitted with the claim for review for 
payment. Narrative demonstrating medical necessity." There has been no clear showing of medical need for a 
surgical removal of the tooth that would necessitate removal of bone in the record.  There is no clear narrative 
expressing why a standard extraction would not be appropriate. As it stands, a lesser code and standard 
extraction would be anticipated but in the event the tooth fractures and requires surgical removal it should be 
clearly documented and submitted for the procedure that was completed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and 
including elevation of mucoperiosteal flap if indicated, tooth #4 (D7210), for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee was medically stable with no evidence of need for supervision by acute 
physical, medicine, and rehabilitation (PMR) or acute rehab nursing care. The enrollee may benefit from 
further physical therapy (PT) and occupational therapy (OT) but does not require an intensive therapy program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia services (10992) provided on February 24, 2020. 
 
You asked the Plan to pay for the anesthesia services. You say that you would like reconsideration because the 
anesthesia services were medically necessary. The Plan denied your request. The Plan says that this level of 
anesthesia was not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 anesthesia services. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the records indicate this was a very serious therapy that would require more than routine 
anesthesia and this degree of monitored anesthesia was appropriate. 
 
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 anesthesia services have been met. Therefore, we decided that the Plan has 
to pay for anesthesia services (10992) provided on February 24, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic procedures (97112) and therapeutic activities 
(97350) provided from November 13, 2019 to November 14, 2019. 
 
You asked the Plan to pay for therapeutic procedures and therapeutic activities. You say that these services 
were medically necessary. The Plan denied your request. The Plan says these services are not supported in the 
records. 
 
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 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 and 97350 is therapeutic activities, direct (one-on-one) 
patient contact (use of dynamic activities to improve functional performance), each 15 minutes. 
 
We find that CPT code 97112 and 97530 is not supported in the medical record.  Specifically, these are time 
based codes. The records do not document the time spent on these services. Based on this information, we 
decided that Medicare rules for coverage of therapeutic procedures and therapeutic activities have not been 
met. Therefore, we decided that the Plan does not have to pay for therapeutic procedures (97112) and 
therapeutic activities (97350) provided from November 13, 2019 to November 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the immunotherapy injections (95117) 
provided on April 20, 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 $35 
copayment per visit to a specialist.  
 
You have been asked to pay a $10.36 copayment for the injections provided at a specialist office visit, 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. 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 immunotherapy 
injections (95117) provided on April 20, 2020.