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 the documentation submitted did not include a physician order/lab requisition or medical records 
stating exactly what tests are to be performed. 
 
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 various denied CPT codes are not supported in the medical record. Specifically, there is no 
valid physician order in the case file to support the denied codes. 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient mental health services provided February 23, 2020 
to March 2, 2020. 
 
You asked the Plan to pay for the inpatient mental health services. You say that inpatient level care was 
medically necessary. The Plan denied your request. The Plan says the enrollee's needs could have been met in a 
lower level of care. Pre-authorization was not obtained for the out-of-network treatment. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the inpatient mental health services. Our 
reviewer says that inpatient level care was not medically necessary. Our physician reviewer found the enrollee 
does not meet the criteria for treatment in an acute inpatient mental health facility and could have been treated 
in a lesser restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or visual 
hallucinations and was being cooperative and compliant. 
 
 
 
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 inpatient mental health services have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient mental health services provided February 23, 2020 to March 2, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a telehealth dermatology visit provided on 
April 9, 2020. 
 
You asked the Plan to waive the copayment for specialist visit. You say that this copayment should be waived 
by the Plan. 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 $15 
copayment for telehealth specialist visit.  
 
You have been asked to pay $15 copayment for specialist visit. Specialist visit falls within the 
Physician/Practitioner Services, Including Doctor's Office Visits benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for a telehealth dermatology visit provided on April 9, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the radiation therapy (77386 x 4)  
provided from March 23, 2020 to March 26, 2020. 
 
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to 
the services provided. 
 
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 $60 
copayment for radiation therapy provided.  
 
You have been asked to pay $240 ($60 copayment x 4 treatments) for the radiation therapy provided. 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 copayments for the radiation therapy (77386 x 4) provided from March 23, 
2020 to March 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic radiology other than CT scan 
(78018x2) provided February 3, 2020 to February 13, 2020. 
 
You asked the Plan to waive the copayment for the diagnostic services. You say that you feel that this amount 
is excessive, especially as the hospital intake registration administrator assured you that there would not be any 
copay for these services. The Plan denied your request. The Plan says the claim was processed and the correct 
copayment has been 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 $275 
copay for diagnostic services other than CT scan services performed by a provider other than your primary care 
physician.  
 
You have been asked to pay $550 for the diagnostic services. There were 2 diagnostic procedures and both 
have a copayment of $275. The diagnostic services fall 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 diagnostic 
radiology other than CT scan (78018x2) provided February 3, 2020 to February 13, 2020.
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 8, 
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 the documentation submitted did not support that the services were performed with blood 
sampling. 
 
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 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
services at issue in this case were not supported by the medical recodrs. Our physician reviewer found blood 
specimen collection is by venipuncture, however, the lab requisition states a urine specimen was collected, 
Also, the laboratory test results for the billed code were not submitted; therefore, the billed service cannot be 
verified. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for drug testing services provided to the enrollee on January 8, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on December 
12, 2019. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Healthcare Common Procedure Coding System (HCPCS) code G0482 (1 unit) remains not 
supported. 
 
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. 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 December 12, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on December 
16, 2019. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says blood specimen collection is by venipuncture; however, the lab requisition states a urine 
specimen was collected; therefore, the billed service 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. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 80159: 
 
Clozapine 
 
CPT 80162: 
 
Digoxin; total 
 
CPT 80173: 
 
Haloperidol 
 
CPT 80201: 
 
Topiramate 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found blood 
specimen collection is by venipuncture, however, the lab requisition states a urine specimen was collected; 
therefore, the billed services cannot be verified.  
It is noted multiple attempts were made to obtain additional information from the provider. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for drug testing services provided to the enrollee on December 16, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lodging expenses related to services received from 
November 30, 2019 to December 31, 2019. 
 
You asked the Plan to pay for lodging expenses. You say that you were hospitalized for chemotherapy and a 
stem cell transplant. You stayed at the Residence Inn and were required to remain close to the hospital. The 
Plan denied your request. The Plan says the services were not provided outside of normal community patterns 
of care. 
 
The Plan must follow Medicare rules. The rules state that when providing an original Medicare service at a 
more distant location, farther away than the normal community patterns of care for transplants, the MA plan 
must ensure that the distant location provides at least the same quality and timeliness of services as at the local 
providers of this service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of lodging expenses have not been met. Specifically, the services related to the lodging expenses at 
issue were provided within distances that are normal for the community patterns of care for transplants. This 
means that the lodging expenses fall outside of the eligibility criteria for reimbursement under Medicare rules. 
Therefore, we decided that the Plan does not have to pay for lodging expenses related to services received from 
November 30, 2019 to December 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmology services provided to the enrollee on 
December 2, 2019. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied codes remain not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 65778: 
 
amniotic membrane on the ocular surface; without sutures 
 
HCPCS L8610: 
 
ocular implant 
 
CPT 65435: 
 
removal of corneal epithelium; with or without chemocauterization 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found the 
documentation is insufficient to support the coding of the above codes. The evidence is insufficient to 
demonstrate that the above services were performed. The eye center medical record dated 12/2/19 documents a 
5-day follow-up of herpes simplex keratitis of the left eye. The following were suggested in the Assessment & 
Plan: localized corneal debridement, AMT OS to accelerate corneal healing and mitigate scar formation in this 
high risk case, topical abx, hold steroid for now, patching at all times, and Tegaderm provided. The medical 
record does not contain a procedure note. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for ophthalmology services provided to the enrollee on December 2, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on November 
22, 2019. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Healthcare Common Procedure Coding System (HCPCS) code G0482 (1 Unit) remains not 
supported. 
 
The Plan must follow Medicare rules. 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. 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 November 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a treatment with a wound vacuum (E2402) 
received on February 12, 2020. 
 
You asked the Plan to waive the coinsurance for a treatment with a wound vacuum. You say that you should 
not be required to pay for treatment of an infection acquired during your surgery. 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 20% 
coinsurance of the cost for Medicare-covered durable medical equipment and related supplies.  
 
The amount you have been asked to pay for a treatment with a wound vacuum, $178.01, is 20% of the total 
cost, $890.07, allowed by the Plan for the service. A treatment with a wound vacuum 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 a treatment with a wound vacuum (E2402) received on February 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive or reduce the cost share charged for outpatient surgery 
services and supplies provided from January 2, 2020 to January 17, 2020. 
 
You asked the Plan to waive or reduce this cost share. You say that you do not believe this cost share is correct. 
The Plan denied your request. The Plan says for outpatient hospital services, there is a $250 copayment per 
visit. The Plan says you had services on January 02, 2020, January 09, 2020, and January 17, 2020. On January 
02, 2020 you also had strapping; Unna boot (29580) with a $135.83 copayment as, you were charged the 
allowed amount which was less than the $250 copayment. On January 09, 2020 you had debridement, 
subcutaneous tissue (includes epidermis and dermis, if performed) with a copayment of $250.00 and on 
January 17, 2020 you had had strapping; Unna boot (29580) with a $135.83 copayment as, you were charged 
the allowed amount which was less than the $250 copayment. These services total $521.66 in copayments. 
 
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 cost 
share for outpatient surgical services and supplies. In this case, for two of the three visits you were charged less 
than the normal $250 copayment. 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 or reduce the cost share charged for outpatient 
surgery services and supplies provided from January 2, 2020 to January 17, 2020.
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 21, 
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 according to the claims data available at the time of the review, the plan was unable to discover 
any evidence of an established relationship between the member and the ordering physician. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 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.  
 
We find that the denied codes are not supported in the medical record. 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. 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 21, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on February 10, 2020. 
 
You asked the Plan to pay for the physician's 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 physician's services provided on February 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an orthopaedic office visit provided on 
March 25, 2020. 
 
You asked the Plan to waive the copayment for office visit. You say that this service was part of a 3-part series, 
so you believe you should only pay 1 copayment for the entire series. 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 $20 
copayment for specialist office visit.  
 
You have been asked to pay $20 copayment for office visit. 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 orthopaedic office visit provided on March 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient hospital visit provided on 
January 9, 2020. 
 
You asked the Plan to waive the copayment for wound care. You say that you were not advised of the 
copayment at the time of your visit. The Plan denied your request. The Plan says the copayment 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 a $300 
copayment for each Medicare-covered outpatient hospital visit.  
 
You have been asked to pay $181.72 for an outpatient hospital visit, which is less than your $300 copayment. 
An outpatient hospital visit falls within the outpatient hospital services 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 outpatient hospital visit provided on January 9, 2020.