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

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on December 30, 2019. 
 
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 records do 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 the denied codes is: 
 
CPT 80157: 
 
Carbamepazine; free 
 
CPT 80159: 
 
Clozapine 
 
CPT 80162: 
 
Digoxin; total 
 
CPT 80173: 
 
Haloperidol 
 
CPT 80177: 
 
Levetiracetam 
 
CPT 80201: 
 
Topiramate 
 
HCPCS G0483: 
 
Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and 
distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, 
GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays 
(e.g., IA,EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope 
or other universally recognized internal standards in all samples (e.g., to control for matrix effects, 
interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched 
quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or 
quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including 
metabolite(s) if performed 
 
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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found the 
documentation submitted did not include a valid physician order or requisition or medical records to support 
the denied codes. Additionally, the billed codes are performed on specimens from blood and blood 
components, and spinal fluid. The submitted lab results indicate that these tests were performed on a urine 
specimen. The billed codes cannot be verified. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for lab services provided to the enrollee on December 30, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on December 26, 2019. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed codes 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab 
requisition stating exactly which testing was to be performed. The records provided do not contain 
documentation of the ordering physician's intent that the tests be performed. 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 26, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on December 19, 2019. 
 
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says that the 
Plan requires utilization of network providers when possible and available, and requires authorization for 
certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency 
situation, has been documented. 
 
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 did not pre-approve the 
psychotherapy services. We found no exception that would require the Plan to pay for these services. 
Therefore, we decided that the Plan does not have to pay for psychotherapy services provided on December 19, 
2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on January 15, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing 
rendered on January 15, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathology services provided on April 7, 2020. 
 
You asked the Plan to pay for the pathology services. The Plan denied your request. The Plan says the Plan 
requires utilization of network providers when possible and available, and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented.   
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for pathology services provided on April 7, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on December 30, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes cannot 
be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab 
requisition stating exactly which testing was to be performed. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the drug testing services provided on December 30, 2019.
Appeal type: Lab
Decision: Unfavorable

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

 
We decided that the Plan does not have to pay for the GeneSight testing services provided on April 20, 2020 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for the testing services. You say that you are the sole provider of the GeneSight 
testing. The Plan denied your request. The Plan says care was not approved in compliance with the plan's 
authorization procedures. 
 
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 did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for the GeneSight testing services provided on April 20, 2020 by 
an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (CPT 82565) provided to the enrollee on 
December 31, 2019. 
 
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 submitted documentation did not include a QW modifier that is required to be appended to 
indicate that the performed is a CLIA-waived test. 
 
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 82565 is "Creatinine; Blood." 
 
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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found CPT 
82565 is required to have QW modifier to indicate that the test performed is a CLIA waived test. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for lab services (CPT 82565) provided to the enrollee on December 31, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on December 18, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing 
rendered on December 18, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for PET of the skull to thigh (78815) provided on March 23, 
2020. 
 
You asked the Plan to pay for the PET. You say that you would like reconsideration because this service was 
medically necessary. The Plan denied your request. The Plan says CPT code 78815 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. 
 
We find that CPT code 78815 is not supported in the record. Specifically, Medicare supplies a list of 
appropriate diagnosis codes for PET procedures. The diagnosis code listed on the claim, C21.0, is not included 
on the list of appropriate codes. Based on this information, we decided that Medicare rules for coverage of the 
PET have not been met. Therefore, we decided that the Plan does not have to pay for PET of the skull to thigh 
(78815) provided on March 23, 2020.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to hold you harmless for a specialist office visit. We decided that the Plan does 
not have to waive the copayment for an aspiration and/or injection and for a Gel-One injection.  
 
You asked the Plan to pay for a specialist office visit, an aspiration and/or injection, and for a Gel-One 
injection. You say that these services were medically necessary. The Plan says that they cannot approve 
payment. 
 
We decided that the Plan has to hold you harmless for a specialist office visit. Medicare rules say that a 
contract provider is an agent of the plan. Services and referrals given by a contract provider are considered 
approved by the plan unless notice is provided that the services will not be covered. The Plan follows these 
rules. 
 
Your specialist office visit was with a contract provider. The file does not show that the Plan provided notice 
that a specialist office visit would not be covered. Under Medicare rules, this means a specialist office visit is 
considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for a specialist 
office visit on January 30, 2020.  
 
We also decided that the Plan does not have to waive the cost-sharing for an aspiration and/or injection 
and for a Gel-One injection. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost 
sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly 
says that you must pay a $35 copayment for physician specialist services and 20% coinsurance for Medicare 
Part B prescription drugs.  
 
You have been asked to pay $35 for an aspiration and/or injection and $214.94, which is 20% of the Plan's 
approved cost $1,074.72, for a Gel-One injection. 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 waive the cost-sharing for an 
aspiration and/or injection of large joint or joint capsule (20610) and a Gel-one injection (J7326) performed on 
February 27, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on July 11, 2018 
through January 2, 2019. 
 
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says S codes are not payable by Medicare. 
 
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 S9328 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT 
code S9328 has a status indicator of I. This means that CPT code S9328 is not valid for Medicare purposes. 
Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not 
been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) 
provided on July 11, 2018 through January 2, 2019.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services provided to the enrollee on December 16, 2019. 
 
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 that these codes are not appropriate for 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 the denied codes is: 
 
CPT 81057: 
 
Carbamepazine; free 
 
CPT 80159: 
 
Clozapine 
 
CPT 80162: 
 
Digoxin; total 
 
CPT 80173: 
 
Haloperidol 
 
CPT 80177: 
 
Levetiracetam 
 
CPT 80201: 
 
Topiramate 
 
HCPCS G0483: 
 
Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and 
distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms 
(any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, 
elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally 
recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in 
signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., 
to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes 
specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed 
 
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 services. Our reviewers say that the 
services at issue in this case were supported by the medical records. Our physician reviewer found the enrollee 
had a comprehensive drug screening test. There was documentation provided that the provider chose the profile 
requested. There are many substances that need to be tested for, and the documentation appears appropriate 
with a signature. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
laboratory services provided to the enrollee on December 16, 2019.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on December 31, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no evidence of 
an established relationship between the member and 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.  
 
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing 
services provided on December 31, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 7, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed codes 
remain 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. 
 
The documentation shows the enrollee received presumptive and definitive drug testing (CPT Codes 80307 and 
G0483). We find the lab services are not supported in the medical record. There is no evidence that shows the 
test was individualized to identify specific non-prescribed medications or illicit substances. 
 
The enrollee also received testing for Carbamazepine, Levetiracetam, Topiramate, Digoxin, Clozapine, and 
Haloperidol. We looked at the file and the rules. This testing is performed on blood, serum, plasma, or 
cerebrospinal fluid. The documentation shows that only a urine sample was provided. 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 January 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extraction of teeth #6-11 and 22-27 (D7140) and 
surgical removal of tooth #21 (D7210). 
 
You asked the Plan to pre-approve extraction of teeth #6-11 and 22-27 and surgical removal of tooth #21. You 
say that the services are necessary. The Plan denied your request. The Plan says the benefit allowance has been 
exhausted. Therefore, coverage criteria has not been met. 
 
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 two non-
surgical or surgical extractions per calendar year. 
 
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 extraction of teeth #6-11 and 22-27 and surgical removal of tooth #21 have not 
been met. Specifically, the benefit allowance has been exhausted. Therefore, we decided that the Plan does not 
have to pre-approve extraction of teeth #6-11 and 22-27 (D7140) and surgical removal of tooth #21 (D7210).