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

We decided that the Plan does not have to pay for the definitive drug testing of 22 or more drug classes 
provided on June 8, 2020, billed with code G0483. 
 
You asked the Plan to pay for the drug testing as billed. You say that this testing should be paid due to medical 
necessity. The Plan denied your request. The Plan says the lab report does not support the billed number of 
drug classes. 
 
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 definitive 22+ classes. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, review of the lab report only 
supports that 21 separately billable drug classes were tested. Based on this information, we decided that 
Medicare rules for coverage of the drug testing as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the definitive drug testing of 22 or more drug classes provided on June 8, 2020, billed 
with code G0483.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on May 5, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you fell and were treated in place by the 
medics. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 5, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on May 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Neuromuscular stimulator provided on June 13, 2020. 
 
You asked the Plan to pay for Neuromuscular stimulator, electronic shock unit (E0745). You say that the Plan 
should pay this claim. The Plan denied your request. The Plan says there is no proof of delivery. 
 
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. There is no delivery 
ticket or proof of delivery. 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 
Neuromuscular stimulator provided on June 13, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for digital breast tomosynthesis (77061) provided on August 4, 
2020. 
 
You asked the Plan to pay for digital breast tomosynthesis. You say that this is a valid code. The Plan denied 
your request. The Plan says this code is not valid for Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 77061 is not supported in the medical record. Specifically, this code has a status 
indicator of ?I.? Medicare uses another code for reporting of, and payment for these services. Based on this 
information, we decided that Medicare rules for coverage of digital breast tomosynthesis have not been met. 
Therefore, we decided that the Plan does not have to pay for digital breast tomosynthesis (77061) provided on 
August 4, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the test panel provided on June 16, 2020. 
 
You asked the Plan to pay for the test panel (87631). You say that the Plan should pay this claim. The Plan 
denied your request. The Plan says that this procedure is non-covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code 87631 is Infectious agent detection by nucleic acid (DNA or RNA); respiratory virus (eg, adenovirus, 
influenza virus, coronavirus, metapneumovirus, parainfluenza virus, respiratory syncytial virus, rhinovirus), 
includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple 
types or subtypes, 3-5 targets.  
 
The rules say that this code is covered in limited places of service. An independent lab is listed as an accepted 
place of service. Medicare coverage criteria are met. Based on this information, we decided that Medicare rules 
for coverage of the test panel (87631) have been met. Therefore, we decided that the Plan has to pay for the test 
panel provided on June 16, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on August 29, 
2020. 
 
You asked the Plan to waive the copayment for an office visit. You say that the doctor did nothing and the X-
ray machine was broken. 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 $10 
copayment for each primary care provider visit.  
 
You have been asked to pay a $10 copayment for an office visit. An office 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 an office visit provided on August 29, 2020.  
 
We note your complaint that the provider did nothing to treat your condition. Your complaint is a grievance 
that must be answered by the health plan. Medicare does not permit us to make a decision about these types of 
complaints.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Magnetic Resonance Imaging (MRI) 
provided on October 8, 2020. 
 
You asked the Plan to waive the copayment for MRI. You say that this MRI was done on the wrong part of 
your body. The Plan denied your request. The Plan says the copayment amount you are being charged is 
correct. 
 
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 $275 
copayment for MRI.  
 
You have been asked to pay the allowed amount of $179.02, which is less than the $275 copayment for MRI. 
MRI falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 Magnetic Resonance Imaging (MRI) provided on October 8, 
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 July 17, 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 July 17, 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 September 23, 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 September 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam CT capture and interpretation (D0364) 
provided on July 30, 2020. 
 
You asked the Plan to pay for the dental service. You say that a panoramic x-ray is covered but the cone beam 
CT is considered a specialized technique. You say that both are forms of x-rays. You also say that if the 
panoramic x-ray is covered then the cone beam CT should be covered too. The Plan denied your request. The 
Plan says one set of x-rays (full mouth series, bitewing x-rays, or panoramic) is payable once per calendar year. 
The Plan also says that services or supplies, as determined by the Dental Plan, which are specialized techniques 
are excluded from coverage. 
 
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 cone 
beam CT capture and interpretation (D0364) provided on July 30, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve an extraction of tooth #10 (D7210). 
 
You asked the Plan to pre-approve dental extraction. You say that you are appealing. The Plan denied your 
request. The Plan says that the denial of authorization for this service is correct, because dental extraction 
(D7210) is not covered by the Plan. 
 
The Plan must follow Medicare rules. Medicare generally does not cover dental services. 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 did not provide any contractual coverage information regarding your 
dental benefits, such as an Evidence of Coverage (EOC) or dental benefit chart. We requested this information, 
but it was not provided to us. Without this documentation, we cannot determine whether the requested 
extraction (D7210) is covered by your Plan?s dental benefits. Therefore, the Plan has not shown that its 
decision to deny authorization for this service is correct or justified according to the Plan contract. Therefore, 
we decided that the Plan has to pre-approve an extraction of tooth #10 (D7210).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cervical/thoracic interlaminar epidural injection for 
the enrollee. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says nothing is known about the problem or what has been done to help the problem. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 the injection. Our reviewer says that the 
requested injection is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the documentation submitted does not clearly delineate the degree and duration of pain relief achieved 
with the first injection. Therefore, the request is deemed not medically reasonable or necessary. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a cervical/thoracic interlaminar epidural injection for the enrollee.
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 August 10, 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 August 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor system 
and related supplies. 
 
You asked the Plan to pre-approve a Freestyle Libre continuous glucose monitor system and related supplies. 
You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says 
you do not meet criteria for the requested items. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
Freestyle Libre continuous glucose monitor system and related supplies have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor system and 
related supplies.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a Positron Emission Tomography scan (Axumin PET/CT) of the 
whole body. 
 
You asked the Plan to pre-approve PET scan. You say that you are in dire need of this PET scan to see if your 
cancer is spreading through your body. The Plan denied your request. The Plan says that the denial of 
authorization for this service is correct, because this scan is indicated only for recurrent prostate cancer, but you 
have newly diagnosed prostate cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
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 PET scan. Our reviewer says that you 
meet the Medicare criteria for the requested PET scan. Our physician reviewer found for a patient with a high 
prostate-specific antigen (PSA) (National Comprehensive Cancer Network (NCCN) high risk group), imaging 
to rule out metastatic disease is necessary. A biopsy would have much greater sensitivity and specificity in 
detecting prostate cancer. Nevertheless, Medicare will cover a PET scan for enrollees who have solid tumors 
that are biopsy proven or strongly suspected based on other diagnostic testing. The results of this PET scan may 
change the treatment plan with respect to radiation fields. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PET scan have been met. Therefore, we decided that the Plan has to pre-
approve a Positron Emission Tomography scan (Axumin PET/CT) of the whole body.  
 
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: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from July 6, 2020, to July 9, 
2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the services provided were medically 
necessary. The Plan denied your request. The Plan says that the inpatient care was not medically necessary and 
lower level of care would have been appropriate. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the patient was admitted due to failure to thrive, dehydration, severe protein calorie 
malnutrition, thyroid abnormalities, and unsafe living condition.  In addition, the patient was hypotensive and 
tachycardic on admission which could support dehydration diagnosis. Documented protein-calorie malnutrition 
was also noted. Patient is felt to be harm to himself in living situation in not being able to care for self. 
Therefore, the admission was medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from July 6, 2020, to July 9, 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee can safely receive the services needed in other settings. 
 
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 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient does require physical therapy and 
occupational therapy services but based on the medical records provided the patient does not require an 
intensive inpatient rehabilitation therapy program. There is concern that the patient will not be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient 
rehabilitation facility due to her present level of pain and weakness. Our physician reviewer found that the 
enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.