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

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on August 3, 
2020. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you thought that copayments 
were waived because of COVID-19 and are unhappy with your Plan. The Plan denied your request. The Plan 
says the claims were processed correctly and you are being charged the correct amount. 
 
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 $40 
copayment for specialist visits.  
 
You have been asked to pay a $40 copayment for a specialist visit. A specialist visit falls within the 
physician/practitioner services, including doctor's office 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. Therefore, we decided that the Plan does not have 
to waive the copayment for a specialist visit provided on August 3, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for diagnostic mammograms provided on 
October 6, 2020. 
 
You asked the Plan to waive the deductible for diagnostic mammograms. You say that you feel that the 
mammogram should be considered preventative. The Plan denied your request. The Plan says the claims were 
processed correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $750 deductible for outpatient diagnostic tests and therapeutic 
services and supplies.  
 
The medical records show that you received diagnostic mammograms on October 6, 2020. The record shows 
that you had only paid $231.57 toward the $750 deductible prior to receiving the services. Therefore, you are 
responsible to pay the total allowed amount of $217.08.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient 
diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $750 deductible for outpatient diagnostic tests and therapeutic services 
and supplies. This cost sharing is a contractual obligation that had not been met at the time diagnostic 
mammograms were received on October 6, 2020. Therefore, we decided that the Plan does not have to waive 
the deductible for diagnostic mammograms provided on October 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture, immediate mandibular 
denture, and extractions. 
 
You asked the Plan to pre-approve the complete maxillary denture, immediate mandibular denture, and 
extractions. The Plan denied your request. The Plan says these services are not covered. 
 
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 covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
complete maxillary denture, immediate mandibular denture, and extractions.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified preventative procedure (D1999), the guided 
tissue regeneration (D4266), and the bone replacement graft for ridge preservation (D7953) provided on 
August 3, 2020. 
 
You asked the Plan to pay for the unspecified preventative procedure, the guided tissue regeneration, and the 
bone replacement graft for ridge preservation. You say that you would like this claim reprocessed and approved 
for payment. The Plan denied your request. The Plan says these services are not covered benefits under your 
supplemental dental benefit. 
 
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 covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
unspecified preventative procedure (D1999), the guided tissue regeneration (D4266), and the bone replacement 
graft for ridge preservation (D7953) provided on August 3, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for fluoroscopic guidance for January 10, 2020. 
 
You asked the Plan to pay for fluoroscopic guidance. You say that the Plan should pay this claim. The Plan 
denied your request. The Plan says fluoroscopic guidance is not supported in the medical record. 
 
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 77002 is Fluoroscopic guidance for needle placement 
(e.g., biopsy, aspiration, injection, localization device) (List separately in addition to code for primary 
procedure).  
 
We find that CPT code 77002 is not supported in the medical record. Specifically, the medical notes state, and 
the images support, that ultrasound guidance was performed. Based on this information, we decided that 
Medicare rules for coverage of fluoroscopic guidance have not been met. Therefore, we decided that the Plan 
does not have to pay for fluoroscopic guidance for January 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Temazepam capsules. 
 
You asked the Plan to pre-approve Temazepam capsules. You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says Temazepam capsules are not covered under the 
enrollee's Medicare Part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Temazepam capsules.  
 
Benefits for Temazepam capsules may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periapical x-ray (D0220) provided on September 30, 
2020. 
 
You asked the Plan to pay for the dental service. You say that you believe that the service was denied due to 
the out of network provider. You say that you made this appointment a year ago. You say that you were not 
aware that the business had been sold during the year. You also say that you were not told when you went for 
your appointment. The Plan denied your request. The Plan says periapical x-ray is not listed as a covered 
service. 
 
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 covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
periapical x-ray (D0220) provided on September 30, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Naltrexone. 
 
You asked the Plan to pre-approve the Naltrexone. You say that you need this specific medication because it is 
the only one that you can take. The Plan denied your request. The Plan says this medication does not fall under 
Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Naltrexone.  
 
Benefits for the Naltrexone may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (HCPCS G0483 and CPT 80307) 
provided to the enrollee on June 11, 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 Healthcare Common Procedure Coding System (HCPCS) code G0483 (1 Unit) and CPT code 
80307 (1 Unit) 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. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
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 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 did not include a physician order to include tests to be performed. The physician order is to 
communicate to the provider services to be performed. 
 
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 drug testing services (HCPCS G0483 and CPT 80307) provided to the enrollee on June 11, 
2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (CPT 61790) provided to the enrollee on 
December 9, 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 procedure is inconsistent with the modifier used. 
 
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 61790 is "Creation of lesion by stereotactic method, 
percutaneous, by neurolytic agent (eg, alcohol, thermal, electrical, radiofrequency); gasserian ganglion." 
 
We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
services at issue in this case were supported by the medical records. Our coding reviewer found CPT 61790 
should be reported with a anatomical-specific modifier.  Documentation should always be reported to highest 
level of specificity, to confirm services provided, as well as anatomical area procedure performed on. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for surgical services (CPT 61790) provided to the enrollee on December 9, 2019.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for portable diagnostic services (Q0092 and R0070) provided to the 
enrollee on June 18, 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 that the transportation and set up costs are subject to consolidated billing and are not separately 
billable to Medicare Part B. 
 
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: 
 
HCPCS Q0092: 
 
Set-up portable x-ray equipment 
 
HCPCS R0070: 
 
Transportation of portable X-ray equipment and personnel to home or nursing home, per trip to facility or 
location, one patient seen 
 
We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
services at issue in this case were supported by the medical records. Our coding reviewer found that the 
documentation includes Place of Service 13 Assisted Living Facility.  Diagnostic X-ray services furnished by a 
portable X-ray supplier are covered under Part B when furnished in a place of residence used as the patient's 
home and in non-participating institutions. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
portable diagnostic services (Q0092 and R0070) provided to the enrollee on June 18, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fluid circulating cold pad with pump (E0218). 
 
You asked the Plan to pre-approve a fluid circulating cold pad with pump. You say that the item is 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. Medicare rules say that a fluid circulating cold pad with pump (E0218) 
will be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a fluid circulating cold pad with pump have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a fluid circulating cold pad with pump (E0218).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for an oral appliance with an out-of-network 
provider. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says oral appliances are available through contracted providers. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a referral for an oral appliance with an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81230, 81231, 81240, 81241, 
81328, 81479 and 81291 provided. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 81230, 81231, 81240, 81241, 81328, 81479 and 81291 is not supported in the medical 
record. Specifically, when a laboratory assays two or more genes in an enrollee in parallel, those two or more 
genes will be considered part of the same panel. A panel constitutes a single procedural service, so one HCPCS 
codes must be submitted for the panel. These services were billed with more than one code. Based on this 
information, we decided that Medicare rules for coverage of the laboratory services have not been met. 
Therefore, we decided that the Plan does not have to pay for the laboratory services coded 81230, 81231, 
81240, 81241, 81328, 81479 and 81291 provided.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to hold you harmless for a determination of refractive state (92015) performed on 
October 8, 2019. 
 
You asked the Plan to hold you harmless for a determination of refractive state. You say that you should not be 
charged for this procedure. The Plan denied your request. The Plan says that this service is normally not 
covered. 
 
Medicare rules say that, for a service or item that is normally not covered, but could be covered under some 
conditions, the EOC alone is not adequate notice of non-coverage. If no notice of non-coverage is given, the 
enrollee is held harmless. The Plan follows these rules. 
 
You received a determination of refractive state from a contract provider. The file does not show that the Plan 
provided notice that a determination of refractive state would not be covered. The service at issue is an example 
of a service that is normally not covered, but could be covered under certain circumstances. Therefore, the 
EOC does not serve as adequate notice of non-coverage in this case. Under Medicare rules, this means a 
determination of refractive state is considered approved by the Plan. Therefore, we decided that the Plan has to 
hold you harmless for a determination of refractive state (92015) performed on October 8, 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of SNF care provided to the enrollee from 
January 23, 2021, forward. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found at the time of admission, the enrollee required 
skilled rehab services to improve function due to weakness and deconditioning.  As of January 22, 2021, the 
enrollee did not require any skilled nursing or rehab services on a daily basis. The enrollee was not expected to 
make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent 
deterioration with mobility or ADLs. The enrollee did not require skilled therapy to establish a safe and 
effective maintenance program. As a practical matter, the enrollee did not require any skilled services on an 
inpatient basis, at a SNF level of care as of January 22, 2021. The enrollee did not have any parental 
medications, complex wound care or nutrition given via a feeding tube. The enrollee received skilled care and 
improved; however, their function had plateaued by January 22, 2021, and they did not require any further 
inpatient skilled rehab services. As of January 23, 2021, the enrollee required custodial services. The denial for 
further inpatient skilled care is upheld. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve continuation of SNF care provided to the enrollee from January 23, 2021, forward.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of SNF care from February 3, 2021, 
forward. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer 
found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service 
needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of 
illness or intensity of service criteria for an inpatient basis in a SNF 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 
SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of 
SNF care from February 3, 2021, forward.