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 February 12, 2021.
You asked the Plan to pay for the drug testing. 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 payable.
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 drugspecific
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 place of service on the
CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The
submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81;
however, the submitted medical documentation and/or claim history indicates that the specimen was obtained
in an office setting place of service 11. 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 February 12, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for hyaluronan gel provided on May 7, 2021. 
 
You asked the Plan to waive the coinsurance for hyaluronan gel. You say that you did not know about any 
changes in coverage. You also say you cannot afford another bill to pay. The Plan denied your request. The 
Plan says you have been charged the correct cost sharing 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay $243.80, which is 20% of the allowed amount for hyaluronan gel ($1,219 allowed 
amount x 20% coinsurance = $243.80). Hyaluronan gel 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. 
Therefore, we decided that the Plan does not have to waive the coinsurance for hyaluronan gel provided on 
May 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided on July 7, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the chiropractic services. You say that you thought this provider was in-network. The Plan denied your request. The Plan says unauthorized, non-plan 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 in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 chiropractic services provided on July 7, 2021 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 extractions, alveoloplasty in conjunction with extractions and unspecified adjunctive procedure provided on June 3, 2021.
You asked the Plan to pay for the extractions, alveoloplasty in conjunction with extractions and unspecified adjunctive procedure. You say that your gums affect your whole body much less being able to not eat. You say that this was not an elective surgery and was absolutely necessary. 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 extractions, alveoloplasty in conjunction with extractions and unspecified adjunctive procedure provided on June 3, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from April 4, 2021, to April 12, 2021, by an out-of-network provider.
You asked the Plan to pay for acute inpatient hospital care. You say that these services were medically necessary and could only have been provided in an acute inpatient setting. The Plan denied your request. The Plan says the inpatient admission was not medically necessary for this enrollee on the dates in question.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. Medicare rules also say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for out-of-network inpatient payment are met in this case. Our physician reviewer found that the enrollee in this case has a history of chronic obstructive pulmonary disease (COPD) and asthma, dementia, hypertension, and benign prostatic hyperplasia. He presented to the out-of-network emergency department on April 4, 2021, with shortness of breath and a cough. A fever was noted. On evaluation, vital signs were stable except for tachycardia. He was treated with supplemental oxygen, oral steroids, intravenous drugs and nebulizers and discharged home on April 11, 2021. His condition stabilized and improved. This review has determined that the record shows that at the time of inpatient admission, the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights. However, the treating physician did not document (in the physician notes, on a form, or in an order) that the enrollee was not stable for transfer on any dates of service. The review has determined that the enrollee was stable and appropriate for transfer to a Plan-contracted facility after the emergency room evaluation on April 4, 2021.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of out-of-network acute inpatient hospital care have not been met. Specifically, the provider in this case is not contracted with the Plan, and the enrollee was stable for transfer to a Plan-contracted facility after emergency evaluation and prior to inpatient admission. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from April 4, 2021, to April 12, 2021, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services coded 99291 provided on September 
23, 2020 to September 27, 2020, the initial hospital care services coded 99223 provided on September 17, 
2020, and the hospital discharge day management services coded 99239 provided on September 28, 2020. 
 
You asked the Plan to pay for the critical care services, the initial hospital care services, and the hospital 
discharge day management 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 99291, 99223, and 99239 are not supported in the medical record. Specifically, the 
medical records do not support that 30-74 minutes of critical care services were provided. This means code 
99291 is not supported by the documentation. The medical records do not support initial hospital care, per day, 
for the evaluation and management of a patient, which requires these 3 key components: A comprehensive 
history; A comprehensive examination; and medical decision making of high complexity. This means code 
99223 is not supported by the documentation. The documentation does not support a hospital discharge day 
management of more than 30 minutes was performed. This means code 99239 is not supported by the 
documentation. 
 
Based on this information, we decided that Medicare rules for coverage of the critical care services, the initial 
hospital care services, and the hospital discharge day management services have not been met. Therefore, we 
decided that the Plan does not have to pay for the critical care services coded 99291 provided on September 23, 
2020 to September 27, 2020, the initial hospital care services coded 99223 provided on September 17, 2020, 
and the hospital discharge day management services coded 99239 provided on September 28, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to hold you harmless for the crown (D2740) provided on December 28, 2020. 
 
You asked the Plan to hold you harmless for the crown. You say that the service should be covered. The Plan 
denied your request. The Plan says that the crown is not medically necessary. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the dental service by a contract provider. The file does not show that the Plan provided 
notice that the dental service would not be covered. Under Medicare rules, this means the dental service is 
considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for the crown 
(D2740) provided on December 28, 2020.  
 
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 pre-approve a group 2 power wheelchair with multiple power
options for the enrollee.
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied
your request. The Plan says this is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.
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 wheelchair. Our reviewer says that
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found the enrollee
has a power mobility device that is less than five years old. The device is malfunctioning but there is no
documentation to indicate that is it beyond repair. Furthermore, the documentation does not indicate that the
enrollee has any pressure injuries or requirement for intermittent catheterization of the bladder.
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 wheelchair have not been met. Therefore, we decided that the Plan does not
have to pre-approve a group 2 power wheelchair with multiple power options for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the programming device evaluation you had at a cardiology clinic on June 4, 2021.
You asked the Plan to waive the copayment for the programming device evaluation. You say that you have never had to pay a copayment for this service in the past. The Plan denied your request. The Plan says you were charged this copayment 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 a $40 copayment for physician and practitioner services in a specialist office. You have been asked to pay a $40 copayment for the programming device evaluation. The programming device evaluation falls within the physician and practitioner services in a specialist office 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 the programming device evaluation you had at a cardiology clinic on June 4, 2021
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the simple repair of superficial wounds (12001) provided on December 31, 2020
You asked the Plan to pay for the simple repair of superficial wounds. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this claim was within the global surgery period and was not coded correctly to indicate this was an unrelated service.
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 12001 is simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the simple repair of superficial wounds have not been met. Specifically, the medical services coded as 26750 and billed on December 13, 2020, have a global surgery period of 90 days. Regarding CPT 12001, this was billed with the -59 modifier which is not an appropriate modifier to bypass the global surgery period edit. Therefore, we decided that the Plan does not have to pay for the simple repair of superficial wounds (12001) provided on December 31, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on August 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.
We looked at the file and Medicare rules. 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 laboratory services rendered on August 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Foundation One testing (81455) provided on April 26, 2021.
You asked the Plan to pay for Foundation One testing. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that genetic testing procedures submitted under code 81455 are unlikely to impact therapeutic decision-making in the clinical management of the patient and will be denied automatically as not medically necessary. We looked at the file and Medicare rules. This testing was submitted with code 81455, which is not covered. Based on this information, we decided that Medicare rules for coverage of Foundation One testing have not been met. Therefore, we decided that the Plan does not have to pay for Foundation One testing (81455) provided on April 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the simple extractions (D7140 x 5) and the surgical
extractions (D7210 x 5) provided on July 14, 2021.
You asked the Plan to pay for the dental services. You say that you were in excruciating dental pain. You also
say that you were concerned about the infection going systematic. The Plan denied your request. The Plan says
there is an annual allowance of $1,000 for covered comprehensive dental services. The Plan also says that the
annual allowance has been exhausted.
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 annual allowance has been
exhausted. The record shows that the Plan paid $962 towards the services that you received on July 14, 2021,
and $38 for services received on June 15, 2021. $962 + $38 = $1,000.
Additionally, the Evidence of Coverage clearly states that after plan paid benefits for comprehensive dental
services, you are responsible for the remaining costs. Therefore, we decided that the Plan does not have to pay
for the simple extractions (D7140 x 5) and the surgical extractions (D7210 x 5) provided on July 14, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency room (ER) services you 
received from July 14, 2021, to July 19, 2021. 
 
You asked the Plan to waive the copayment for the ER services. You say that your doctor said you could not be 
treated on an outpatient basis because attempts to manage your condition as an outpatient failed. The Plan 
denied your request. The Plan says you were charged this copayment correctly. The Plan says that these 
services were not denied, but this claim represents your cost sharing 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 $90 
copayment for emergency room services.  
 
Records show that you went to the ER on July 14, 2021.  You were then kept in observation until July 19, 
2021.  The billing records show that you were not admitted as an inpatient, but rather kept in observation 
(which is an outpatient status) until your discharge on July 19, 2021. You have been asked to pay a $90 
copayment for the ER services. 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 emergency room (ER) 
services you received from July 14, 2021, to July 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve electronic connection between wheelchair controller identified with code E2311.
You asked the Plan to pre-approve electronic connection between wheelchair controller. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested item is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that electronic connection between wheelchair controller is only covered for certain 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 electronic connection between wheelchair controller. Our reviewer says that the documentation does not support that the requested item is medically reasonable or necessary. Our physician reviewer found the documentation shows that you have 3 out of 5 bilateral hand and wrist strength. You are independent with feeding, grooming and upper extremity dressing thus indicating that you have adequate upper extremity strength and function to control the wheelchair's power options with their own switches. Therefore, you do not meet criteria for the requested item. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of electronic connection between wheelchair controller have not been met. Therefore, we decided that the Plan does not have to pre-approve electronic connection between wheelchair controller identified with code E2311.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an upholstered chair with seat lift mechanism purchased from a retail furniture store on December 2, 2020.
You asked the Plan to pay for durable medical equipment purchased from a retail furniture store. You say that this lift chair should be covered by the Plan. The Plan denied your request. The Plan says durable medical equipment can only be obtained from Medicare eligible providers to be covered by the Plan or by 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 by a vendor who is not a Medicare eligible provider. The furniture store confirmed that they are not a Medicare eligible provider. Therefore, we decided that the Plan does not have to pay for an upholstered chair with seat lift mechanism purchased from a retail furniture store on December 2, 2020.