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

 
We decided that the Plan does not have to pay for the colposcopy services coded 57454 provided on March 16, 
2020. 
 
You asked the Plan to pay for the colposcopy 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. 
 
In this case, the CPT Code Manual definition of code 57454 is colposcopy of the cervix including 
upper/adjacent vagina; with biopsy(s) of the cervix and endocervical curettage. 
 
We find that CPT code 57454 is not supported in the medical record. Specifically, the documentation does not 
support that the services were provided by the provider on the claim. Therefore, this provider is inaccurately 
billed. Based on this information, we decided that Medicare rules for coverage of the colposcopy services have 
not been met. Therefore, we decided that the Plan does not have to pay for the colposcopy services coded 
57454 provided on March 16, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transport provided on March 
3, 2020. 
 
You asked the Plan to waive the copayment for the ambulance transport. You say that you should not have to 
pay this because you were admitted to the hospital. The Plan denied your request. The Plan says that you are 
contractually obligated to pay appropriate copayment for services rendered. 
 
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 $220 
copayment for Medicare-covered ambulance benefits.  
 
You have been asked to pay a $220 copayment for the ambulance transport. The ambulance transport falls 
within the Medicare-covered ambulance benefits 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 the ambulance transport provided on March 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment (L1833) provided on 
February 4, 2020. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the proof of delivery is not 
valid. 
 
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 for the supplies provided in this case. 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 the durable medical equipment (L1833) provided on February 4, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pulp vitality tests and the core build up services provided 
on March 25, 2020. 
 
You asked the Plan to pay for the pulp vitality tests and the core build up services. You say that you would like 
the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a 
covered 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 pulp 
vitality tests and the core build up services provided on March 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services (98940) provided on February 4, 
2020 to April 7, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for OON chiropractic services. You say that you were not told these services needed 
authorization. The Plan denied your request. The Plan says OON services require 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 chiropractic services (98940) provided on 
February 4, 2020 to April 7, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from October 7 to 
October 14, 2019. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you should not be 
responsible for this cost-sharing. 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 $395 
copayment for each day for days 1 to 4 for Medicare-covered hospital care.  
 
You have been asked to pay a $1,580 copayment, or a $395 copayment for each day for days 1 to 4, for an 
inpatient hospital stay. An inpatient hospital stay falls within the Inpatient Hospital 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 inpatient hospital stay from October 7 to October 14, 
2019.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic radiology services provided on March 20, 2020 
and May 13, 2020. 
 
You asked the Plan to pay for the diagnostic radiology services. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require 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 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 diagnostic radiology services provided on March 20, 2020 and 
May 13, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services (CPT 80053) provided to the enrollee on March 23, 
2020. 
 
You asked the Plan to pay for the services. You say that thus was billed correctly. The Plan denied your 
request. The Plan says that this claims needs to be resubmitted with a modifier for processing. 
 
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. The plan's denial reason is vague. The plan has not stated what modifier needs to 
be used on the corrected claim. The plan has not substantiated their denial. Therefore, we decided that the Plan 
has to pay for laboratory services (CPT 80053) provided to the enrollee on March 23, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on May 6, 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 the testing is not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on May 6, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the occupational therapy services (97035, 97110, 97140, 
97530) provided on March 25, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for OON occupational therapy services. You say that you believed you were in-
network. The Plan denied your request. The Plan says this service was 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 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 occupational therapy services (97035, 97110, 
97140, 97530) provided on March 25, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 2, 2020. 
 
You asked the Plan to pay for the lab 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 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 January 2, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transportation provided on March 29, 2020. 
 
You asked the Plan to pay for ambulance transport. You say that the service was billed with appropriate 
diagnosis codes. The Plan denied your request. The Plan says the denial of payment for this service is correct, 
because the records do not support the medical necessity of transportation by ambulance. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance transport. Our reviewer says that 
this ambulance transportation does not meet the Medicare criteria for payment. Our physician reviewer found 
based on the records submitted there is no documentation that other means of transport were contraindicated 
for the enrollee. There is no documentation that the enrollee needed the expertise, services, and life-saving and 
life-sustaining equipment that only a fully equipped ambulance can provide for safe transport. There is no 
documentation to support that the ambulance transportation on March 29, 2020 was medically reasonable and 
necessary for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ambulance transport have not been met. Therefore, we decided that the Plan 
does not have to pay for ambulance transportation provided on March 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the root amputation (D3450) provided on March 3, 2020. 
 
You asked the Plan to pay for the root amputation (D3450). You say that you expected the procedure to be 
covered at 50%.  The Plan denied your request. The Plan says the service is not a covered 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 root 
amputation (D3450) provided on March 3, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81163, 81317, 81307, 81408, 
81404, 81405, 81408, and 81435 provided on February 6, 2020. 
 
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 were billed incorrectly. 
 
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 codes 81163, 81317, 81307, 81408, 81404, 81405, 81408, and 81435 are not supported in the 
medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of 
the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was 
obtained in a laboratory, place of service 81, however, the submitted medical documentation and/or claim 
history indicates that the specimen was obtained in an office setting place of service 11. 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 81163, 81317, 
81307, 81408, 81404, 81405, 81408, and 81435 provided on February 6, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on December 16, 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 December 16, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on December 18, 2019. 
 
You asked the Plan to pay for the drug testing. You say that this testing should be covered. The Plan denied 
your request. The Plan says there is no valid order specifying what drugs are requested for testing. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing may be covered when ordered by the 
treating provider. 
 
The file includes a form ordering the "Chronic Care Management Profile". The drugs/drug classes to be tested 
are not specified. Without documentation of the classes intended to be tested, the coverage criteria have not 
been met. Therefore, we decided that the Plan does not have to pay for the drug testing provided on December 
18, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on January 28, 2020. 
 
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 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 January 28, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on December 13, 2019. 
 
You asked the Plan to pay for the lab 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the billed CPT codes are not supported in the medical record. Specifically, the services were billed 
as if the specimen was collected by blood sampling. However, the records show that the specimen was 
collected by urine sample. 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 13, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the targeted genomic sequence analysis services coded 
0037U provided on September 24, 2019. 
 
You asked the Plan to pay for the targeted genomic sequence analysis 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 a 
covered benefit. 
 
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 0037U is targeted genomic sequence analysis, solid organ 
neoplasm, DNA analysis of 324 genes, interrogation for sequence variants, gene copy number amplifications, 
gene rearrangements, microsatellite instability and tumor mutational burden. 
 
We find that CPT code 0037U is not supported in the medical record. Specifically, the documentation does not 
include a physician order or lab requisition for this testing provided. Based on this information, we decided that 
Medicare rules for coverage of the targeted genomic sequence analysis services have not been met. Therefore, 
we decided that the Plan does not have to pay for the targeted genomic sequence analysis services coded 
0037U provided on September 24, 2019.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services received from February 9, 2020 to 
February 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 this was provided by a non-certified provider. 
 
Medicare rules say that services must be provided by providers who are enrolled in the Medicare program. 
 
The rendering provider in this case not eligible to bill Medicare. The Plan did not pre-approve the 
services. 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 home health services received from February 9, 
2020 to February 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided 
from March 1, 2020 to March 4, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you should not 
have to pay because you were discharged early. The Plan denied your request. The Plan says that the 
copayment 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 $295 
copayment for each day for days 1 to 6 for Medicare-covered hospital care.  
 
You have been asked to pay a $885 copayment for the inpatient hospital services. The inpatient hospital 
services falls within the days 1 to 6 for Medicare-covered hospital 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 the inpatient hospital services provided from March 1, 2020 to 
March 4, 2020.