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

 
We decided that the Plan does not have to pay for injection services (CPT 65556 and CPT 64447) provided to 
the enrollee on April 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 claim was processed correctly with the way it was submitted. 
 
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 64445 - injection of anesthetic agent/steroid into sciatic nerve 
 
CPT 64447 - injection of anesthetic agent/steroid into femoral nerve 
 
We find that the denied CPT codes are not supported in the medical record. Specifically, this was not billed 
with the correct modifier to indicate these services are distinct procedures. Without the modifiers, these codes 
would be considered part of the anesthesia code already billed - CPT 01232 - and not separately billable. 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 injection services (CPT 65556 and CPT 64447) provided to 
the enrollee on April 17, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the physical therapy (PT) services 
rendered from January 22, 2020 to February 18, 2020. 
 
You asked the Plan to waive the copayments for these services. You say that you were told you would have a 
$5 copayment. The Plan denied your request. The Plan says the copayments were applied correctly. 
 
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 $30 
copayment for Medicare-covered physical therapy visits.  
 
Review of the file shows that you had seven PT visits from January 22, 2020 to February 18, 2020. You have 
been asked to pay a $30 copayment per visit for these services for a total of $150. These services fall within the 
Medicare-covered physical therapy visits 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.  
 
The file shows that you call the Plan on January 22, 2020 and asked what your copayment would be for an 
orthopedic specialist visit. You were advised that the specialist copayment was $5 per visit. There is no record 
that you were told that there was a $5 copayment for PT. 
 
Therefore, we decided that the Plan does not have to waive the copayments for the physical therapy (PT) 
services rendered from January 22, 2020 to February 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient care provided from February 7, 2020, to 
February 9, 2020. 
 
You asked the Plan to pay for the inpatient care. The Plan denied your request. The Plan says the enrollee was 
stable for transfer at the time of admission. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 inpatient care. Our reviewer says that the 
requested inpatient care was not medically reasonable and necessary. Our physician reviewer found that the 
enrollee was hemodynamically stable and appropriate for ambulance transport with monitoring to a plan 
facility for observation/admission level of care services. There was no documentation provided requiring post-
stabilization care services from February 7, 2020, to February 9, 2020, at the non-Plan facility. The post-
stabilization care services were medically necessary or reasonable. The treating physician did not document (in 
the physician notes, on a form, or in an order) that the enrollee was not stable for transfer on any dates of 
service. 
 
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 inpatient care have not been met. Therefore, we decided that the Plan does 
not have to pay for the inpatient care provided from February 7, 2020, to February 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from February 10
to February 18, 2020.
You asked the Plan to waive the copayment for an inpatient hospital stay. You ask that your copayment be
eliminated under the Plan's offer of a cost-sharing waiver for certain services due to to the COVID-19
pandemic. 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 $390
copayment for each day for days 1-5 of Medicare-covered hospital care and a $0 copayment for additional
Medicare-covered days.
You have been asked to pay a $1,950 copayment, or a $390 copayment for each of the first 5 days, for an
inpatient hospital stay. An inpatient hospital stay falls within the Inpatient Hospital Care benefit category. The
Plan's cost-sharing waiver does not apply to inpatient hospital services. 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 inpatient hospital stay from February 10 to February 18, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT scan provided by a participating 
provider on March 7, 2020. 
 
You asked the Plan to waive the copayment for radiology services. You say that this was recommended to have 
after a kidney removal. The Plan denied your request. The Plan says the correct copayment has been 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 $250 
copayment for outpatient diagnostic tests/in-network/CT scan.  
 
You have been asked to pay a $250 copayment for radiology services. Since a CT scan was provided, the 
correct copayment has been applied. Radiology services falls within the outpatient diagnostic tests/in-
network/CT scan 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 a CT scan provided 
by a participating provider on March 7, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paramedic intercept services. 
 
You asked the Plan to pay for the paramedic intercept services. You say that you feel you should only have to 
pay the ambulance copayment requirement for these services. The Plan denied your request. The Plan says this 
item is not a covered benefit. 
 
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. 
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area.  
 
The paramedic intercept services at issue in this appeal were not furnished in a rural area. Therefore, we 
decided that the Plan does not have to pay for the paramedic intercept services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for oxygen equipment purchased on February 4, 2020.
You asked the Plan to pay for oxygen equipment. You say that you are requesting reimbursement for these
items. The Plan denied your request. The Plan says the denial of payment for these items is correct, because
purchased oxygen equipment is not covered.
The Plan must follow Medicare rules. Medicare rules say that only rented oxygen equipment is eligible for
coverage and purchased oxygen equipment is statutorily non-covered.
We looked at the file and Medicare rules. These items are not reimbursable when purchased. Based on this
information, we decided that Medicare rules for coverage of oxygen equipment have not been met. Therefore,
we decided that the Plan does not have to pay for oxygen equipment purchased on February 4, 2020.
Appeal type: Practitioner Services
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 March 18, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
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 March 18, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded G0483 provided on January 29, 2020. 
 
You asked the Plan to pay for the drug 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. 
 
In this case, the CPT Code Manual definition of code G0483 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; 22 or 
more drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation does not 
support any evidence of an established relationship between the enrollee and the ordering physician. Based on 
this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, 
we decided that the Plan does not have to pay for the drug testing coded G0483 provided on January 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral dental x-rays (D0220) March 19, 2020. 
 
You asked the Plan to pay for the x-rays. You say that you told the dentist not to perform anymore x-rays and 
you should not be liable for the services. The Plan denied your request. The Plan says your benefits were 
exhausted and the non-covered services were performed. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those specifically covered under this benefit. In addition, the $2,000 allowance for other dental services 
was exhausted at the time services were rendered. Therefore, we decided that the Plan does not have to pay for 
intraoral dental x-rays (D0220) March 19, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on July 17, 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 July 17, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assistant at surgery services provided on October 28, 2019. 
 
You asked the Plan to pay for assistant at surgery services. You say that the surgeon deemed these services 
medically necessary for the enrollee, and there likely was not access to an in-network provider. The Plan 
denied your request. The Plan says the denial of payment for these services is correct, because the services 
were performed by a Certified First Assistant (CFA) which is not recognized for payment by Medicare. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for assistant at surgery services provided 
on October 28, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the progressive lenses and anti-reflective coating rendered on 
February 19, 2020. 
 
You asked the Plan to pay for these services. You say that you received a temporary pair of glasses that were 
deluxe but only got a basic pair. The Plan denied your request. The Plan says the services are not covered 
benefits. 
 
The Plan must follow Medicare rules. Medicare rules say that progressive lenses are non-covered and anti-
reflective coating is covered when medically necessary. 
 
We looked at the file and Medicare rules. The progressive lenses are non-covered by Medicare for all 
indications. The file does not show that the anti-reflective coating was billed by your provider as medically 
necessary. Therefore, we decided that the Plan does not have to pay for the progressive lenses and anti-
reflective coating rendered on February 19, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on November 26, 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 submitted 
does not include a physician order, lab requisition, or medical records stating exactly which tests were to be 
performed and some of the lab tests billed do not match the specimen type for testing. 
 
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.  
 
We looked at the file and Medicare rules. 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 November 26, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on January 15, 
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 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 
 
CPT 80307: 
 
Drug test(s), presumptive, any number of drug classes, qualitative; any number of devices or procedures, by 
instrument chemistry and analyzers (e.g., utilizing immunoassay [EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), 
chromatography (e.g., GC, HPLC), and mass spectrometry either with or without chromatography, (DAT, 
DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when 
performed, per date of service 
 
We find that the denied codes are not supported in the medical record. Specifically, there is no valid physician 
order for these services, and the services were done by urine sampling rather than blood sampling. 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 drug testing services provided to the enrollee on January 15, 
2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on January 5, 2020. 
 
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 submitted 
does not include a physician order, lab requisition, or medical records stating exactly which tests were to be 
performed and some of the tests billed do not match the specimen type for testing. 
 
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.  
 
We looked at the file and Medicare rules. 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 January 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen concentrator and sales tax purchased on February 
28, 2020. 
 
You asked the Plan to pay for the services. You say that it was impossible to take your large oxygen tank 
outside of your home. The Plan denied your request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. Review of the file shows that you 
purchased the oxygen concentrator and paid for sales tax on February 28, 2020. The rules say that only rented 
oxygen equipment is eligible for coverage. Purchased oxygen equipment is statutorily non-covered. 
Furthermore, your Plan does not make any additional payment for sales taxes and do not make adjustments in 
fees to reflect local changes in tax rates. Therefore, we decided that the Plan does not have to pay for the 
oxygen concentrator and sales tax purchased on February 28, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an Emergency Room Visit (99284) 
provided March 12, 2020. 
 
You asked the Plan to waive the copayment for the Emergency Room Visit. 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 $90 
copayment for Emergency Care.  
 
You have been asked to pay a $90 copayment for the Emergency Room Visit. The Emergency Room Visit falls 
within the Emergency 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 an 
Emergency Room Visit (99284) provided March 12, 2020.