Persius/hicric huggingface dataset:
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 9, 
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 these codes are not appropriate for the services billed. 
 
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 81057: 
 
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. 
 
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 9, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 10, 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 10, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a stay at a SNF from March 10 to April 
15, 2020. 
 
The enrollee asked the Plan to waive the copayments for a stay at a SNF. The enrollee said that a representative 
of the SNF informed them that there would be no copayment for their stay. The Plan denied the enrollee's 
request. The Plan says the correct copayments were 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). The enrollee's contract with the Plan clearly says that enrollees must 
pay a $20 copayment for days 1-20 of their stay at a SNF and a $178 copayment for days 21-100 of their stay.  
 
The enrollee has been asked to pay $2,085 for a 36-day stay at a SNF. A stay at a SNF falls within the "Skilled 
nursing facility (SNF) care" benefit category. A 36-day stay would bear a costs-sharing of $3,248 (20 days x 
$20 + 16 days x $178). This means that the enrollee has been asked to pay less than the full amount based on 
their contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay when they 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for a stay at a 
SNF from March 10 to April 15, 2020.  
 
The enrollee's complaint about being given misleading or erroneous information by a representative of the SNF 
is not a valid appeal for medical coverage. This part of the enrollee's complaint is a grievance that must be 
answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for durable medical equipment (E0651, E0667) provided 
February 24, 2020. 
 
You asked the Plan to pay for the durable medical equipment. You say that the items were medically necessary. 
The Plan denied your request. The Plan says valid proof of delivery has not been provided to the health plan in 
a timely manner. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and valid proof of delivery.  
 
The record does not contain a valid proof of delivery which support medical necessity for the supplies provided 
in this case. The proof of delivery was not provided to the plan in a timely fashion. The proof of delivery 
provided consists of a shipping receipt that is not signed and is not itemized. It does not provide the address to 
which the items were delivered. 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 durable medical 
equipment (E0651, E0667) provided February 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on April 22, 2020 by an out of
network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained.
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 physician services provided on April 22, 2020 by
an out of network (OON) provider.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Home infusion/specialty drug administration provided on 
January 2, 2020. 
 
You asked the Plan to pay for Home infusion/specialty drug administration. You say that the Plan should pay 
this claim. The Plan denied your request. The Plan says these codes are not valid for Medicare purposes. 
 
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 99601, 99602 is Home infusion/specialty drug 
administration. 
 
We find that CPT code 99601, 99602 are I codes, not used and payable by Medicare for these services. Based 
on this information, we decided that Medicare rules for coverage of Home infusion/specialty drug 
administration have not been met. Therefore, we decided that the Plan does not have to pay for Home 
infusion/specialty drug administration provided on January 2, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services. 
 
You asked the Plan to pay for the ambulance services. You say that you are diabetic and on the date of service 
you lost consciousness. You say that you had low blood sugar and you passed out while at your sister's home. 
You stated that you were unresponsive and so an ambulance was called for you. You asked the Plan to 
reconsider providing coverage for the services. 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 March 27, 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental implants provided on September 30, 2019. 
 
You asked the Plan to pay for dental implants. You say that this was medically necessary. The Plan denied your 
request. The Plan says this is not covered by Medicare or the Plan. 
 
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 dental 
implants provided on September 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an osteogenesis ultrasound stimulator (E0760) provided 
on November 26, 2019. 
 
You asked the Plan to pre-approve an osteogenesis ultrasound stimulator. You say that this should be paid. The 
Plan denied your request. The Plan says documentation showing this was medically necessary has not been 
submitted. 
 
 
The Plan must follow Medicare rules. Medicare rules say that an ultrasonic osteogenesis stimulator is covered 
only if there is a nonunion of a fracture documented by a minimum of two sets of radiographs obtained prior to 
starting treatment with the osteogenesis stimulator.  
 
We looked at the file and Medicare rules. No radiographs have been submitted to show criteria have been met. 
Based on this information, we decided that Medicare rules for coverage of an osteogenesis ultrasound 
stimulator have not been met.  Therefore, we decided that the Plan does not have to pre-approve an 
osteogenesis ultrasound stimulator (E0760) provided on November 26, 2019.
Appeal type: Lab
Decision: Unfavorable

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

 
We decided that the Plan does not have to pay for the laboratory services rendered on February 11, 2020. 
 
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 screening tests are 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 February 11, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on April 3, 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 respiratory infectious agent detection, code 87633, is non-covered by Medicare and is excluded 
from coverage. 
 
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 87633 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, 12-25 targets." 
 
We find that CPT code 87633 is not supported in the medical record, as it is statutorily not covered by 
Medicare. 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 lab services provided to the enrollee on April 
3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy (90832) rendered by the out of network 
(OON) provider on August 7, 2019. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the psychotherapy (90832) rendered by the out of network (OON) provider on August 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit (99334) rendered by the 
out of network (OON) provider on December 30, 2019. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the domiciliary or rest home visit (99334) rendered by the out of network (OON) provider on 
December 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral speech device evaluation (92597) rendered by the 
out of network (OON) provider on May 18, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the oral speech device evaluation (92597) rendered by the out of network (OON) provider on 
May 18, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a coronary angiography (93458) performed on March 2, 2020.
You asked the Plan to waive the coinsurance for a coronary angiography. You say that this coinsurance presents a financial hardship. The Plan denied your request. The Plan says the correct cost-sharing 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 20% coinsurance for each Medicare-covered radiological diagnostic service, not including X-rays. You have been asked to pay $803.50, or 20% of the Plan-allowed cost of $4,017.52, for a coronary angiography. A coronary angiography 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 coinsurance for a coronary angiography (93458) performed on March 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a biopsy of the breast (19081) performed on February 18, 2020.
You asked the Plan to waive the coinsurance for a biopsy of the breast. You say that you were not made aware of any charges for this service and that you can't afford to pay the balance. The Plan denied your request. The Plan says the correct coinsurance 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 40% coinsurance for outpatient surgery obtained out of network. You have been asked to pay 540.11 or 40% of the Plan-approved cost of $1,350.28 for a biopsy of the breast. A biopsy of the breast falls within the Outpatient Surgery 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 coinsurance for a biopsy of the breast (19081) performed on February 18, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdomen x-ray rendered on May 13, 2020. 
 
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 procedure code 74019 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 74019 and 74022. Code 74019 is a column II code with a 
modifier indicator of 1 when billed with column I code 74022. Code 74019 was not billed with an appropriate 
modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the 
abdomen x-ray rendered on May 13, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 3, 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 February 3, 2020.