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

 
We decided that the Plan does not have to pay for the definitive drug testing provided on February 3, 2020. 
 
You asked the Plan to pay for the drug testing. The Plan denied your request. The Plan says 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 code G0482 is definitive drug testing of 15-21 drug classes. 
We find that CPT code G0482 is not supported in the medical record. In this case, there is insufficient records 
to show that the testing was ordered based on the enrollee's specific indications, including historical use, 
medication response, and clinical assessment, to make clinical decisions. Based on this information, we 
decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the definitive drug testing provided on February 3, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for two CT scans provided by a participating 
provider on June 18, 2020. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you should only have a $100 
copayment. The Plan denied your request. The Plan says the correct copayments have 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 a $100 
copayment for outpatient diagnostic tests/in-network/advanced imaging service.  
 
You have been asked to pay a $100 copayment for each CT scan. You have been asked to pay a total of $200 
($100 x 2 CT scans = $200). Since two CT scans were provided, the correct copayments have been applied. A 
CT scan falls within the outpatient diagnostic tests/in-network/advanced imaging service 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 two CT scans provided by a participating provider on June 
18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on December 19, 2019. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed services 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that 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. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on December 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthoses (L3740, L3916, L4396, L2820, L2340, L2830 
and L3995). 
 
You asked the Plan to pay for the orthoses. You say that the documentation supports that they were necessary. 
The Plan denied your request. The Plan says the documentation submitted did not include an itemized 
shipping/billing invoice to indicate the specific supplies or 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. 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 orthoses (L3740, L3916, L4396, L2820, L2340, L2830 and 
L3995).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan of the lower spine performed on
October 1, 2018.
You asked the Plan to waive the copayment for a CT scan of the lower spine. You say that you should not be
responsible for paying this charge so long after the date of service. The Plan denied your request. The Plan says
the correct copayment was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275
copayment for advanced imaging services at a freestanding radiological facility.
You have been asked to pay a $275 copayment for a CT scan of the lower spine. A CT scan of the lower spine
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 a CT scan of the lower spine performed on October 1, 2018.
Your complaint that you were charged for this service so long after the date of service is not a valid appeal for
medical coverage. This part of your 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided January 21, 2020. 
 
You asked the Plan to pay for laboratory services. You say that you would like reconsideration based on the 
medical records provided. The Plan denied your request. The Plan says the documentation submitted indicates 
that the services were administered by a different provider. 
 
The Plan must follow Medicare rules. The rules say that the provider, supplier, or beneficiary, as appropriate, 
must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the 
amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of laboratory services have not been met. Specifically, provider information listed on the claim form 
submitted does not match the billing provider. Therefore, we decided that the Plan does not have to pay for 
laboratory services provided January 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 panel rendered on April 17, 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 the claim was not billed correctly.
The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure code 81479. The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 panel rendered on April 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral x-ray and limited oral evaluation. 
 
You asked the Plan to pay for the intraoral x-ray. You submitted your bills for review. You say that you have a 
dental credit to use. The Plan denied your request. The Plan says the services are not covered benefits. 
 
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 
intraoral x-ray and limited oral evaluation.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 80157, 80159, 80162, 80173, 
80201, and G0483 provided on January 24, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services 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 80157, 80159, 80162, 80173, 80201, and G0483 are not supported in the medical 
record. Specifically, the documentation submitted did not include a completed physician order/lab requisition 
form or medical records stating exactly what tests were to be performed. Based on this information, we decided 
that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory services coded 80157, 80159, 80162, 80173, 80201, and G0483 
provided on January 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on March 4, 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. The 
Plan says that the member's primary care physician did refer these services. 
 
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 March 4, 2020 by 
an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab tests provided on February 28, 2020 by an out of network 
(OON) provider. 
 
You asked the Plan to pay for lab tests. 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. The Plan says that 
the member's primary care physician did not refer these service. 
 
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 lab tests provided on February 28, 2020 by an out 
of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on December 9, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the testing is not covered. 
 
The Plan must follow Medicare rules. The rules say that testing to confirm that a urine specimen is 
unadulterated is an internal control process that is not separately reportable. 
 
We looked at the file and Medicare rules. The file shows that the tests at issue were urine specimens utilized for 
drug testing. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on 
December 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on April 2, 2020 to 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 2, 2020 to 
April 22, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on January 16, 2020 billed with codes 80157, 80177, 80201, 80162, 80159, and 80173.
You asked the Plan to pay for the billed testing. You say that this testing was medically necessary and should be covered. The Plan denied your request. The Plan says these tests require blood samples and the documentation shows that only a urine sample was obtained.
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 codes billed are not supported. These codes describe testing done using a sample of serum or plasma. The sample in this case was not serum/plasma. Based on this information, we decided that Medicare rules for coverage of the billed testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing provided on January 16, 2020 billed with codes 80157, 80177, 80201, 80162, 80159, and 80173.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service provided on August 21, 2019. 
 
You asked the Plan to pay for the ambulance service. You say that the ambulance service was medically 
necessary. The Plan denied your request. The Plan says the enrollee could have been safely transported by 
another type of vehicle. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
We looked at the file and Medicare rules. The record shows the enrollee, complaining of constipation was 
ambulatory, conscious, stable, in no acute respiratory or cardiac distress and had no sign of injury, stroke, or 
hemorrhage. Neither oxygen nor emergency treatment was needed for transport. Based on this information, we 
decided that Medicare rules for coverage of the ambulance service have not been met. Therefore, we decided 
that the Plan does not have to pay for the ambulance service provided on August 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services you received from September 19, 2019, to 
December 18, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider has opted 
out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
the services you received from September 19, 2019, to December 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level.

You asked the Plan to pre-approve a repeat nerve block (64493). You say that the enrollee's pain has not responded to physical treatments, medications or recent injection. The Plan denied your request. The Plan says criteria is not met for a repeat procedure.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file, and Medicare rules. Medical records from February 11, 2020 show the procedure on November 19, 2019 only gave 20% relief. Based on this information, we decided that Medicare rules for coverage of a repeat nerve block (64493) have not been met. Therefore, we decided that the Plan does not have to pre-approve injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on December 26, 2019. 
 
You asked the Plan to pay for drug 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 valid physician 
order or clear intent to order the specific lab services billed on this claim. Based on this information, we 
decided that Medicare rules for coverage of drug tests have not been met. Therefore, we decided that the Plan 
does not have to pay for drug testing provided on December 26, 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 October 9, 
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. Therefore, we decided that the Plan does not have to pay for drug testing services 
provided to the enrollee on October 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on March 9, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for home health 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. The 
Plan says that the member's primary care physician did not refer these services. 
 
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 home health services provided on March 9, 2020 
by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on January 28, 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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a
physician who has furnished a consultation or treats an enrollee for a specific medical problem.
The file does not contain documentation of an established relationship between the enrollee and the ordering
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this
testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing
rendered on January 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on February 25, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that these services are provided in good faith. 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 February 25, 2020 
by an out of network (OON) provider.