Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99203) and chiropractic 
manipulative treatment (98941) provided on June 4, 2020 to June 9, 2020 by an out of network (OON) 
provider. 
 
You asked the Plan to pay for the office visit and chiropractic services. You say that you were not in 
Philadelphia and could not consult with your regular doctor. Given the circumstances and steps you have taken 
to stay safe during this pandemic, you thing this minor expense should be covered. The Plan denied your 
request. The Plan says enrollee's must receive their medical services from an in-network provider with the 
exception being urgent or emergent services. Non-emergent services with non-contracted providers require 
prior authorization before services being rendered. 
 
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 outpatient office visit (99203) and chiropractic 
manipulative treatment (98941) provided on June 4, 2020 to June 9, 2020 by an out of network (OON) 
provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for needle electromyography (95886), nerve conduction studies (95912) 
and train of four monitoring (95999) provided on August 16, 2019. 
 
You asked the Plan to pay for the neuromonitoring services. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says that the medical records submitted do 
not support the services billed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the record indicates that the Plan utilized clinical information in 
medical records to make their decision. The Plan did not forward the medical records used to make this 
decision. It is the burden of the Medicare Health Plan to substantiate the denial with evidence. The denial is not 
substantiated and we must find in your favor. Therefore, we decided that the Plan has to pay for needle 
electromyography (95886), nerve conduction studies (95912) and train of four monitoring (95999) provided on 
August 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 June 1, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services 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 G0482 is "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; 15-21 
drug class(es), including metabolite(s) if performed". 
 
We find that CPT code G0482 is not supported in the medical record. Specifically, the records provided do not 
support the testing of 15-21 drug classes on the date of service in question. 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 June 1, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on January 21, 2020 and 
billed under codes 80157, 80177, 80201, 80162, 80159, and 80173. 
 
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 the documentation submitted did not support that were performed with blood sampling.  
Blood specimen collection is by venipuncture; however, Documentation submitted does not indicate that a 
blood/serum specimen was collected in order to support the billed code.  Therefore, the validity and accuracy 
of the claim cannot be verified. Of note, the submitted blood/serum requisition did not contain the billed test. It 
is noted multiple attempts were made to obtain additional information from the provider. 
 
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 claim submitted cannot be paid 
due to an issue with the specimen reported. 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 21, 2020 and billed under 
codes 80157, 80177, 80201, 80162, 80159, and 80173.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services provided on January 17, 2019, through 
December 31, 2019. 
 
You asked the Plan to pay for the outpatient services. You say that you would like reconsideration for these 
claims. The Plan denied your request. The Plan says these claims need to be submitted to your primary 
insurance. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed you 
to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the 
outpatient services until the primary insurer has denied the claim for these services. Therefore, we decided that 
the Plan does not have to pay for outpatient services provided on January 17, 2019, through December 31, 
2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $50 copayment charged for urgent care services provided 
on May 29, 2020. 
 
You asked the Plan to waive this copayment. You say that you went to get tested for Covid because you did not 
feel well. You do not feel this copayment should be charged. The Plan denied your request. The Plan says this 
copayment was charged based on the claim submitted by the provider, the treatment records and the Plan 
contract agreement. 
 
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 $50 
copayment for urgent care services. The medical records state you presented to urgent care for a cough and 
requested you be tested for Covid as you thought there was possible exposure. The cough was mild and dry. No 
other symptoms were reported. No other Covid symptoms were reported. The diagnosis was treatment for 
cough. The records indicate you were told the test results would be revealed in a few days and that if your 
symptoms worsened you should call your primary care physician. You self-referred to urgent care. The medical 
records do not show that you were treated for a positive diagnosis of Covid. You were not referred to urgent 
care by a physician under suspicion of being positive for Covid. 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 $50 copayment 
charged for urgent care services provided on May 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diabetic shoes. 
 
You asked the Plan to pre-approve diabetic shoes. You say that these have been approved in the past. The Plan 
denied your request. The Plan says these are not covered for your condition. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. The records 
show that you have pre-diabetes. Although orthotics may be appropriate for you, neither Medicare nor the Plan 
provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-
approve diabetic shoes.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided to the enrollee on February 4, 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 the claim submitted did not report code 81479 which is required for this testing. 
 
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 claim submitted cannot be paid 
due to an omission of a required claim for this type of testing.  Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pay for lab testing provided to the enrollee on February 4, 2020.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the 
enrollee's nursing, medical and rehabilitation needs do not require an acute rehab hospital inpatient stay with 
an interdisciplinary approach to rehabilitation care. The member does not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy 
program. 
 
The member continues to have a need for skilled therapy with ongoing safety concerns and a potential for 
functional improvement however, the documentation doesn't support that he would meet criteria for admission 
to an acute inpatient rehabilitation facility.  There is no indication that the member would require skilled 
rehabilitation in an IRF, participating in rehab services 15 hours a week, under the supervision of a physician 
with at least 3 visits weekly to regain or maintain his functional status.  The member is ambulating up to 400 
feet with a walker.  He is near his prior level of function and could receive services at a lower level of care. 
 
 
 
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: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on November 4, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or 
provider must corroborate the documentation in the beneficiary's medical documentation and confirm that 
Medicare coverage criteria have been met. 
 
We looked at the file and Medicare rules. The documentation provided does not contain medical records from 
the non-contract provider. Without records, it cannot be determined that Medicare coverage criteria have been 
met. Therefore, we decided that the Plan does not have to pay for the services provided on November 4, 2019.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services you received on July 8, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says an explanation of 
benefit is required from the primary insurer. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has identified the 
primary insurer. As the secondary insurer, the Plan cannot be held responsible for the services until the primary 
insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the 
services you received on July 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a neck/back orthosis (L0457) provided June 27, 2020. 
 
You asked the Plan to pay for the orthosis. You say that this item was 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, or relevant medical records which support medical 
necessity for the supplies provided in this case. The records do not show any history of the referring provider 
listed on the claim ever treating this patient. The record shows the plan contacted the provider's office and 
confirmed they had no record of the patient being treated. 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 a neck/back orthosis (L0457) provided June 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-covered chiropractic services provided on July 16, 2020. 
 
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The 
Plan denied your request. The Plan says coverage of chiropractic service is specifically limited to treatment by 
means of manual manipulation by use of the hands. No other diagnostic or therapeutic service furnished by a 
chiropractor or under the chiropractor's order is covered. Examples of other diagnostic or therapeutic services 
that are not covered include office visits, ultrasound, massage, heat application, electrical stimulation or   x-
rays. The Plan states that the services denied are not covered by Medicare.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not 
manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for non-covered 
chiropractic services provided on July 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for non-covered chiropractic services provided on June 22, 
2020. 
 
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The 
Plan denied your request. The Plan says services provided that were not related directly to manual manipulation 
of the spine are not covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not 
manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for non-covered 
chiropractic services provided on June 22, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on June 15, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
approved in advance. 
 
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 services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider 
on June 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for testing services provided to the enrollee on June 16, 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 Medicare criteria requires the billing of code 81445 or 81479 to qualify for payment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, the claim submitted cannot be paid as 
billed due to the omission of the codes required for this service. Medicare rules for coverage of this service 
have not been met. Therefore, we decided that the Plan does not have to pay for testing services provided to the 
enrollee on June 16, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 12, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for these services. You say that the services should be covered. The Plan denied 
your request. The Plan says the services were 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 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 laboratory services provided on June 12, 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 provided to the enrollee on April 15, 2020 and billed under codes 80157, 80177, 80201, 80162, 80159 and 80173.
You asked the Plan to pay for lab services. You say that this claim should be paid. The Plan denied your request. The Plan says the documentation submitted did not support that the denied codes were performed with blood sampling. Blood specimen collection is by venipuncture; however, the lab requisition states a urine specimen was collected; therefore, the billed service cannot be verified. It is noted multiple attempts were made to obtain additional information from the provider.
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 claim cannot be paid as billed due to an issue with the reported specimen. Medicare billing criteria were not met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on April 15, 2020 and billed under codes 80157, 80177, 80201, 80162, 80159 and 80173.