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

 
We decided that the Plan does not have to pay for the therapeutic drug assays provided on November 11, 2019 
for carbamazepine, levetiracetam, topiramate, digoxin, clozapine, and haloperidol. 
 
You asked the Plan to pay for the drug assays. You say that this testing was medically necessary and should be 
covered. The Plan denied your request. The Plan says the individual drug assays are not supported in the 
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. 
 
We find that codes at issue are not supported in the medical record. Specifically, these codes described testing 
which requires serum or plasma. There is no evidence that blood was drawn in this case. Based on this 
information, we decided that Medicare rules for coverage of the drug assays have not been met. Therefore, we 
decided that the Plan does not have to pay for the therapeutic drug assays provided on November 11, 2019 for 
carbamazepine, levetiracetam, topiramate, digoxin, clozapine, and haloperidol.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on March 7, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider 
on March 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the new patient office or other outpatient visit (99201) 
provided on July 4, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the new patient office or other outpatient visit. You say that the services provided 
were medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained by 
the facility or the provider; therefore, payment has been correctly denied. In addition, the services provided 
were not an emergency or urgently needed. 
 
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 new patient office or other outpatient visit 
(99201) provided on July 4, 2020, by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office outpatient visit (99213) provided on January 11, 
2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that you were not aware this service needed a prior 
authorization. The Plan denied your request. The Plan says prior authorization must be obtained for non-
emergent services rendered by an out-of-network provider. 
 
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 office outpatient visit (99213) provided on 
January 11, 2020 by an out of network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on May 11, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says due to the enrollee's hospice election at the time, this claim should be submitted to 
Original Medicare. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit 
for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for 
physician services provided to the enrollee on May 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion visits provided on January 7, 2020 and 
January 8, 2020 billed with codes 99601 and 99602. 
 
You asked the Plan to pay for the home infusion visits. You say that these services were medically necessary 
and should be covered. The Plan denied your request. The Plan says the codes used for these services are not 
valid for Medicare billing. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
CPT codes 99601 and 99602 have a status indicator of "I" on the Physician Fee Schedule, meaning that they 
are invalid for Medicare billing purposes. Based on this information, we decided that Medicare rules for 
coverage of the home infusion visits have not been met. Therefore, we decided that the Plan does not have to 
pay for the home infusion visits provided on January 7, 2020 and January 8, 2020 billed with codes 99601 and 
99602.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diffusing capacity services coded 94729 and the 
plethysmography for determination of lung volumes services coded 94726 provided on November 7, 2019. 
 
You asked the Plan to pay for the diffusing capacity services and the plethysmography for determination of 
lung volumes 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 codes 94729 and 94726 are not supported in the medical record. Specifically, the submitted 
medical records do not support that this code was performed. Therefore, code 94726 remains not supported. 
The required primary service code (94726) is denied; therefore, code 94729 cannot be separately reimbursed. 
Based on this information, we decided that Medicare rules for coverage of the diffusing capacity services and 
the plethysmography for determination of lung volumes services have not been met. Therefore, we decided that 
the Plan does not have to pay for the diffusing capacity services coded 94729 and the plethysmography for 
determination of lung volumes services coded 94726 provided on November 7, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says your 
condition no longer requires daily skilled services. 
 
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. 
 
Continued services beyond October 24, 2020, were requested. 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 continued services. Our physician reviewer found that from a nursing perspective, you 
received oral medications, and had stable vital signs. There are no identifiable skilled nursing service needs. 
Regarding rehab services, you are at a standby assist level with functional mobility. You require varying assist 
with activities of daily living. 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 continued services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the established patient office or other outpatient visit and 
smoking and tobacco use intermediate counseling (99214, 99406) provided on March 24, 2020, by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the established patient office or other outpatient visit and smoking and tobacco 
use intermediate counseling. You say that no authorization is needed for services rendered under telemedicine. 
The Plan denied your request. The Plan says prior authorization was not obtained by the facility or the 
provider; therefore, payment has been correctly denied. 
 
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 established patient office or other outpatient 
visit and smoking and tobacco use intermediate counseling (99214, 99406) provided on March 24, 2020, by an 
out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says there is no need 
for daily skilled services. 
 
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 services. Our physician reviewer 
found that from a nursing perspective, the enrollee received oral medications, and had stable vital signs. There 
are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee is at a standby assist 
level for functional mobility. He requires varying assist for activities of daily living. Although there are 
identifiable skilled therapy service needs, the enrollee does not require skilled nursing or therapy services on a 
daily basis. The enrollee does 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the full amount for the immediate upper denture (D5130) 
provided on January 6, 2020. 
 
You asked the Plan to pay the full amount for the dental item. You say that you chose this plan because there 
were no copayments. You say that there is no mention of the dental coverage amount of $150. You also say 
that this should be listed so that you know what to expect. The Plan denied your request. The Plan says the 
$150 allowance for non-Medicare covered preventive and comprehensive dental services. The Plan says that 
the allowance has been exhausted. The Plan also says you are responsible for any amount above the dental 
coverage limit. 
 
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 $150 dental allowance has been 
exhausted. The Evidence of Coverage clearly states there is a $150 allowance for non-Medicare covered 
preventive and comprehensive dental services. The record shows that the Plan applied the $150 allowance to 
the denture and you are responsible for the remaining amount. Therefore, we decided that the Plan does not 
have to pay the full amount for the immediate upper denture (D5130) provided on January 6, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy (HIT) administrative services 
provided from January 8, 2020, through March 11, 2020 billed with code S9328. 
 
You asked the Plan to pay for the HIT administrative services. You say that these services are necessary for the 
use of the enrollee's pain pump. The Plan denied your request. The Plan says this code is not payable 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. 
 
CPT code S9328 has a status indicator of "I" on the Physician Fee Schedule, meaning it is invalid for Medicare 
billing purposes. Based on this information, we decided that Medicare rules for coverage of the HIT 
administrative services have not been met. Therefore, we decided that the Plan does not have to pay for the 
home infusion therapy (HIT) administrative services provided from January 8, 2020, through March 11, 2020 
billed with code S9328.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a lumbar epidural steroid injection. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says that 
there is no documentation of pain relief greater than 50% of at least 2-3 months duration from the prior 
injection. 
 
The Plan follows Medicare rules. Medicare rules say that lumbar epidural steroid injections are only covered 
under certain medical indications.  
 
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 requested services. Our physician 
reviewer found that the enrollee has chronic low back pain and right leg pain. He has Alzheimer's dementia and 
has care giver. He takes Gabapentin and had physical therapy. He has had Epidural Steroid injections in the 
past. It is most important to recognize that those with dementia may not be able to express pain scores 
effectively by themselves. Their caregivers are better able to assess their pain via verbal and non-verbal clues.  
The wife relates that he gets 10 weeks of pain relief and better functioning after each injection. Therefore, the 
request is 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 the requested services have been met. Therefore, we decided that the Plan has to 
pre-approve a lumbar epidural steroid injection.  
 
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 waive the coinsurance for the walker provided on May 18, 2020. 
 
You asked the Plan to waive the coinsurance for the walker. You say that you would like additional 
reimbursement. The Plan denied your request. The Plan says that you were reimbursed the Medicare allowable 
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 20% 
coinsurance for Durable medical equipment (DME) and related supplies.  
 
You have been asked to pay a 20% coinsurance for the walker. The walker falls within the Durable medical 
equipment (DME) and related 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 the walker provided on May 18, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Home Infusion services (99601) provided December 10, 
2019 to December 23, 2019. 
 
You asked the Plan to pay for the Home infusion services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the code billed is not valid for Medicare payment. 
 
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 99601 is not supported in the medical record. Specifically, per the National Physician 
Fee Schedule, procedure code 99601 has a status code of "I" which is not valid for Medicare purposes. Based 
on this information, we decided that Medicare rules for coverage of the Home infusion services have not been 
met. Therefore, we decided that the Plan does not have to pay for Home Infusion services (99601) provided 
December 10, 2019 to December 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on June 18, 2020. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that this second consult 
was necessary. The Plan denied your request. The Plan says this service exceeds the frequency limitation in 
your benefit 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, problem focused limited oral 
evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem 
focused limited oral evaluation (D0140) on February 25, 2020, and your problem focused limited oral 
evaluation (D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for 
the problem focused limited oral evaluation (D0140) provided on June 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit (99213) to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve office visit. You say that you believe the request provider is more qualified to address your needs. The Plan denied your request. The Plan says services must be rendered by an in-network provider.

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 the office visit (99213) to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown and core buildup, including any pins when 
required provided on July 8, 2020. 
 
You asked the Plan to pay for the crown and core buildup. You say that the office staff told you that these 
services would be covered. The Plan denied your request. The Plan says these services are not covered. The 
Plan also says that you were presented with and signed a treatment plan that shows these services were not 
covered by your insurance, and you would be fully responsible for the charges. 
 
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 crown 
and core buildup, including any pins when required provided on July 8, 2020.