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

 
We decided that the Plan does not have to pay for the drug testing coded G0483 provided on July 26, 2022. 
 
You asked the Plan to pay for the drug testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services billed are 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 code G0483 is 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. 
 We find that CPT code G0483 is not supported in the medical record. Specifically, the submitted 
documentation does not include an order for 22 or more drug classes in the order form. 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 drug testing coded G0483 provided on July 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided September 5, 2022, to 
September 8, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that the notice of denial of medical 
coverage stating the enrollee was admitted to the hospital for weakness is inaccurate and ambiguous. The 
enrollee was treated for pneumonia with an antibiotic IV and was sent to the nursing home a few days later. 
The Plan denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided September 5, 2022, to September 8, 2022.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 72170 billed for date of service September 
19, 2022. 
 You asked the Plan to pay for procedure code 72170. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 72170 is bundled into payment for code 72190. 
 
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, we have confirmed that code 72170 
is a column II code to column I code 72190. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 72170 billed for date of service September 19, 
2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the continuous intraoperative neurophysiology monitoring (G0453) 
provided on January 28, 2022. 
 
You asked the Plan to pay for the continuous intraoperative neurophysiology monitoring. You say that this 
service was ordered by an in-network surgeon, and provided at an in-network facility. You also say that the 
surgeon applied their medical knowledge and expertise to determine that this service was medically necessary 
for the enrollee. The Plan denied your request. The Plan says that the precertification entity was not contacted 
for precertification. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The provided documentation did not show whether the treating surgeon is in-
network or out-of-network with the Plan. Without this information, we are unable to determine if the Plan's 
denial is valid. Therefore, we decided that the Plan has to pay for the continuous intraoperative 
neurophysiology monitoring (G0453) provided on January 28, 2022.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted Molecular Pathology services (81479) provided 
July 31, 2022. 
 
You asked the Plan to pay for the pathology services. You say that you believe that the biomarker testing 
services should be covered because they were ordered by an in-network physician and the results are medically 
necessary to provide the best care for the enrollee. The Plan denied your request. The Plan says this service is 
not a covered benefit per CMS. 
 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. The requested testing needs to be on the DEX: Diagnostics 
Exchange Registry MolDX. This test was not listed on the approved list of molecular genetic test. Based on 
this information, we decided that Medicare rules for coverage of the pathology services have not been met. 
Therefore, we decided that the Plan does not have to pay for the unlisted Molecular Pathology services (81479) 
provided July 31, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an arthrocentesis provided on November 15, 2021. 
 
You asked the Plan to pay for an arthrocentesis. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an arthrocentesis 
provided on November 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an onabotulinumtoxinA injection provided to the enrollee on 
March 4, 2022. 
 
You asked the Plan to pay for the injection. You say that this was medically necessary. The Plan denied your 
request. The Plan says there is no documentation of axillary hyperhidrosis. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the injection. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the record indicates that the enrollee has a diagnosis of focal hyperhidrosis of the scalp. The Food 
and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. The 
Medicare-approved drug compendia do not contain a supportive citation for the use of the requested drug in the 
enrollee's clinical situation. The noted condition is not an enumerated one for which coverage is available under 
the local coverage determination. The elements of the coverage criteria are not satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not 
have to pay for an onabotulinumtoxinA injection provided to the enrollee on March 4, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Part B drugs provided on June 23, 2022. 
 
You asked the Plan to waive the coinsurance for Part B drugs. You say that this should be covered. The Plan 
denied your request. The Plan says this cost sharing was charged correctly. 
 
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 Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for Part B drugs. This item/service falls within the Medicare Part 
B prescription drugs 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. You have been asked to pay $58.47 which is 20% of the allowed amount for the chemotherapy 
drugs. Therefore, we decided that the Plan does not have to waive the coinsurance for Part B drugs provided on 
June 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cervical facet injections provided on August 2, 2022. 
 
You asked the Plan to pay for cervical facet injections. You say that the cervical facet injections were 
medically necessary. The Plan denied your request. The Plan says the only medical notes received are imaging 
results from the past decade. There were no doctor notes related to the procedure done on August 2, 2022. 
Complete doctor notes for the procedure done on August 2, 2022 are needed to determine if the procedure is 
medically needed. 
 
The Plan must follow Medicare rules. Medicare 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 there is insufficient 
information in the record to determine if Medicare rules for coverage of cervical facet injections have been met. 
Specifically, there are no medical records provided for this date of service. Therefore, we decided that the Plan 
does not have to pay for cervical facet injections provided on August 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CXbladder detect test (0012M) provided on May 27, 
2022. 
 
You asked the Plan to pay for the CXbladder detect test. You say that this service was medically necessary. 
The Plan denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are 
non-covered.  
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the CXbladder detect test have not been met. Therefore, we 
decided that the Plan does not have to pay for the CXbladder detect test (0012M) provided on May 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab service within a facility provided on August 03, 2022. 
 
You asked the Plan to pay for lab service within a facility. You say that we depend upon the facility staff to 
verify eligibility and to obtain authorization. The Plan denied your request. The Plan says that unauthorized, 
out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for lab service within a 
facility provided on August 03, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the apicoectomy (D3425), retrograde filling (D3430), and 
guided tissue regeneration (D4266) provided on June 22, 2022. 
 
You asked the Plan to pay for the apicoectomy, retrograde filling, and guided tissue regeneration. You say that 
these procedures should be covered by your dental plan and medical plan. The Plan denied your request. The 
Plan says you did not receive an extraction in preparation of the jaw for radiation treatments. The Plan also 
says that these services are not covered benefits under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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. Specifically, the provided documentation shows that these services 
were rendered due to an infection and persistent pain after root canal therapy. These services are considered to 
be dental in nature, and not medical. Therefore, we decided that the Plan does not have to pay for the 
apicoectomy (D3425), retrograde filling (D3430), and guided tissue regeneration (D4266) provided on June 22, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for vision service provided on April 5, 2022. 
 
You asked the Plan to waive the deductible for vision service. You say that you are disputing the share cost. 
The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $91.60 
deductible for Vision services. Your in-network and out-of-network medical deductible is $225. This is the 
amount you have to pay out-of-pocket before the Plan will pay their share for your covered medical services. 
 
You have been asked to pay $91.60 deductible for vision service. This item/service falls within the Vision 
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 deductible for vision service provided on 
April 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) provided on June 9, 2022. 
 
You asked the Plan to pay for the evaluation and management service. You say that you were advised that the 
provider would be able to treat the enrollee even though the provider has opted out of Medicare, per the 
verification of benefits. The Plan denied your request. The Plan says the provider in this case has opted out of 
Medicare. The Plan also says that payment cannot be made for services performed by a provider that 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 who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the office 
visit (99214) provided on June 9, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mental health telehealth care provided on September 01, 
2022. 
 
You asked the Plan to pay for the mental health telehealth care. You say that the provider is supposed to be in-
network. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the mental health 
telehealth care provided on September 01, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a skilled nursing facility visit provided on April 29, 2022. 
 
You asked the Plan to pay for a skilled nursing facility visit. You say that the service was medically necessary 
and provided in good faith. The Plan denied your request. The Plan says that unauthorized, out-of-network care 
is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a skilled nursing facility 
visit provided on April 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on September 7, 2022. 
 
You asked the Plan to pay for 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 September 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the needle electromyography; larynx (95865), and 
neuromuscular junction testing (95937) provided on July 25, 2022. 
 
You asked the Plan to pay for the intraoperative neurophysiologic monitoring (IONM). You say that the 
services were medically necessary. The Plan denied your request. The Plan says the services in this case are not 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that nerve conduction studies and electromyography 
are only covered for diagnosis codes that support medical necessity. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the intraoperative neurophysiologic monitoring (IONM) have not been met. Specifically, the 
diagnosis code lists on the claim does not support that the services in this case were medically necessary. 
Therefore, we decided that the Plan does not have to pay for the needle electromyography; larynx (95865), and 
neuromuscular junction testing (95937) provided on July 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital services provided on 
July 27, 2022, to July 28, 2022. 
 
You asked the Plan to waive the copayment for outpatient hospital services. You say that you are disputing the 
share cost. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $200 
copayment for outpatient hospital observation.  
 
You have been asked to pay $200 copayment for outpatient hospital services. This item/service falls within the 
outpatient hospital observation 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 
outpatient hospital services provided on July 27, 2022, to July 28, 2022.  
 Your complaint about your experience at the waiting room 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.