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

 
We decided that the Plan does not have to pay for a COVID-19 test taken in Switzerland to fly to California. 
 
You asked the Plan to pay for this test. You say that this test should be covered by the Plan since it was 
required for you to board the plane home. The Plan denied your request. The Plan says the COVID -19 
test was performed exclusively for travel purposes with no evidence of exposure or symptoms to meet the 
medical necessity for urgent or emergent unforeseen medical condition 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. You chose to travel during a pandemic. This test was requested solely for screening purposes, out of the 
country, and without the need to treat a medical condition. Medicare does not cover this test solely for 
screening purposes for travel. Therefore, we decided that the Plan does not have to pay for a COVID-19 test 
taken in Switzerland to fly to California.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pay for the Esophagogastroduodenoscopy (EGD) (endoscopy) provided on July 1, 2020.
You asked the Plan to pay for the Esophagogastroduodenoscopy (EGD) (endoscopy). You say that you provided your insurance card and was seen the same day for the procedure. You say there was no documentation of cost that you would owe provided to you before the procedure. The Plan denied your request. The Plan says that there is no record of an approved authorization for the endoscopy.
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. Specifically, the Plan has not provided us with the network status of the physician or facility that rendered these services. The Plan has not provided us with the network status of the referring physician. Therefore, we decided that the Plan has to pay for the Esophagogastroduodenoscopy (EGD) (endoscopy) provided on July 1, 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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve stereotactic body radiation therapy (SBRT) for the enrollee. 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your 
request. The Plan says that three dimensional conformal radiation therapy (3D-CRT) would be approved if 
requested. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 therapy. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found the treatment offered to this enrollee - SBRT to sites of oligoprogression - including nodal sites- could be 
considered to be furnished in accordance with accepted standards of medical practice, acknowledging that the 
data supporting this treatment continue to arise. For this specific case it appears that the treatment of the nodal 
metastases is disputed. While the ASTRO model policy does not specify nodal metastases, it is generally 
accepted safe (when staying within accepted dosimetric constraints) and effective. 
 
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 therapy have been met. Therefore, we decided that the Plan has to pre-
approve stereotactic body radiation therapy (SBRT) for the enrollee.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0483) provided April 8, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the place of service listed on 
the claim (81, laboratory) does not match the place of service detailed in the records (11, office setting). 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 lab services (G0483) provided April 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dermatology services you received on September 28, 2021, 
from an out-of-network provider. 
 
You asked the Plan to pay for the dermatology services. You say that payment has been made in the past for 
this provider's services under your out-of-network benefit. The Plan denied your request. The Plan says this 
provider has opted-out of Medicare, so no payment can be made for these services. 
 
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 
dermatology services you received on September 28, 2021, from an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 16, 2021. 
 
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 services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have 
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on July 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 26, 2021. 
 
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 services are not covered. 
 The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 84480 and 84481. Code 84480 is a column II code with a 
modifier indicator of 1 when billed with column I code 84481. Code 84480 was not billed with an appropriate 
modifier to allow for separate payment. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have 
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on January 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete maxillary denture (D5110) and complete 
mandibular denture (D5120) provided on October 12, 2021. 
 
You asked the Plan to pay for the dentures. You say that you would like this bill to be paid because you bought 
dental insurance knowing it was going to help you pay for the teeth you have now. The Plan denied your 
request. The Plan says denturists are not contracted providers with the Plan, and any services provided by them 
are not covered. 
 
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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the 
complete maxillary denture (D5110) and complete mandibular denture (D5120) provided on October 12, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic procedure (CPT code 97110-GP, CQ, KX) 
provided on September 8, 2021. 
 
You asked the Plan to pay for the therapeutic procedure. You say that the claim should be paid. The Plan 
denied your request. The Plan says the service is not supported by the records. 
 
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 97110 is therapeutic procedure, 1 or more areas, each 15 
minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. 
 
CPT code 97110-GP, CQ, KX (4 units) remains not supported. CPT code 97110 represents therapeutic 
procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of 
motion and flexibility. The medical records indicate that Physical Therapy Assistant visit was performed by 
Physical Therapy Assistant in home setting. There is a more appropriate Healthcare Common Procedure 
Coding System (HCPCS) code G0157 that should be used to bill for the service provided. Therefore, the billed 
CPT code, modifier and units cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information. Based on this information, we decided that Medicare rules for coverage of 
the therapeutic procedure have not been met. Therefore, we decided that the Plan does not have to pay for the 
therapeutic procedure (CPT code 97110-GP, CQ, KX) provided on September 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) testing rendered
on November 12, 2021.
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 urinalysis is the standard of care for UTI.
We looked at the file and Medicare rules. The file shows that the services at issue exceeded the standard of care
for the diagnosis and treatment of a UTI. 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
urine polymerase chain reaction (PCR) testing rendered on November 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory service (CPT code 84480) provided on February 24, 2021.
You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 84481 and 84480. This PTP edit has a modifier indicator of 0, which indicates there are no modifiers that are allowed with this PTP code pair. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory service (CPT code 84480) provided on February 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 5, 2021. 
 
You asked the Plan to pay for the lab services. You say that you have provided medical records to support 
payment for these services. The Plan denied your request. The Plan says you billed an incorrect Place of 
Service code on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place 
where the sample was taken is reported as the Place of Service (POS). Records show that you billed with a POS 
of 81, indicating independent laboratory.  However, the records show that the specimen was collected from the 
patient in an outpatient hospital setting, so the POS should have been 22.  
We looked at the file and Medicare rules. 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 lab 
services provided on April 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve primary care physician (PCP) services to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the PCP services. You say that you were told that this PCP was in-network. 
The Plan denied your request. The Plan says the PCP that the enrollee is requesting to see is a non-contracting 
PCP. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
primary care physician (PCP) services to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a duplex scan provided to the enrollee on June 15, 2021. 
 
You asked the Plan to pay for the scan. You say that this should be paid for. The Plan denied your request. The 
Plan says the medical record clearly indicates that CPT 93970 was performed in this case, not CPT 93971. 
 
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 93971 is "Duplex scan of extremity veins including 
responses to compression and other maneuvers; unilateral or limited study." 
 
We asked our coder 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 scan. Our reviewer says that the services at issue in this 
case were not supported by the medical records. Our reviewer found the report of the duplex scan of the lower 
extremities done on 6/15/21 clearly documents bilateral lower extremity exam was done consistent with CPT 
93970 for bilateral lower extremities, rather than CPT 93971 which is used for unilateral. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the scan have not been met. Therefore, we decided that the Plan does not have 
to pay for a duplex scan provided to the enrollee on June 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory pathogen panel provided on August 18, 2020. 
 
You asked the Plan to pay for the laboratory panel. You say that this was medically necessary testing. The Plan 
denied your request. The Plan says the POS code used is not correct. 
The Plan must follow Medicare rules. Medicare rules say that for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. The documentation does not indicate this sample was taken by the 
lab directly. As such, the use of POS code 81 is not supported. Based on this information, we decided that 
Medicare rules for coverage of the laboratory panel have not been met. Therefore, we decided that the Plan 
does not have to pay for the respiratory pathogen panel provided on August 18, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mass spectrometry and tandem mass spectrometry (CPT 
code 83789-59) provided on July 30, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not supported by the records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
CPT code 83789-59 remains not supported. This code represents a not elsewhere specified code. However, a 
complete description of the not elsewhere specified code was not included. The order/lab requisition must be 
signed and dated and must include what laboratory test was ordered/requested in order to validate the not 
elsewhere specified code billed. Of not, the medical records provided indicate that the urine specimen was collected for drug testing. When specimen validity testing is conducted as part of drug testing, it cannot be 
billed separately. Therefore, the billed code and modifier cannot be verified. It is noted that multiple attempts 
were made to contact the provider for additional information. Based on this information, we decided that 
Medicare rules for coverage of the laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for mass spectrometry and tandem mass spectrometry (CPT code 83789-59) provided on 
July 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by a participating provider on 
November 10, 2021. 
 
You asked the Plan to pay for dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says the maximum allowance benefit amount of $2,000 has already been 
reached. 
 
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. The Plan covers dental 
services up to a $2,000 maximum allowance amount.  
 
We looked at the file and Medicare rules. Evidence was provided to show that the maximum allowance amount 
of $2,000 was met on May 10, 2021.  Based on this information, we decided that the Plan's rules for coverage of dental services have not been met. 
Therefore, we decided that the Plan does not have to pay for dental services provided by a participating 
provider on November 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from March 10, 2022, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from March 10, 2022, forward. You say that the 
services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are 
not medically necessary. 
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 pre-approve inpatient psychiatric care from March 
10, 2022, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient mental 
health treatment beyond the date in question of March 10, 2022, forward. Our physician reviewer found the 
enrollee did not require inpatient mental health treatment beyond March 10, 2022, as she was not a danger to 
herself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active 
treatment was taking place beyond the date in question. It did not appear that the services for the dates in 
question were reasonably expected or medically necessary to improve the enrollee's condition or for the 
purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from March 10, 2022, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from March 10, 2022, forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) provided 
on November 24, 2020. 
 
You asked the Plan to pay for a comprehensive periodontal evaluation. You say that you received 
misinformation from the Plan stating the provider was in-network. You also say the representative did not 
mention the evaluation would not be covered. The Plan denied your request. The Plan says the requested 
service is not covered under your benefit Plan under any normal circumstance. 
 
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 a 
comprehensive periodontal evaluation (D0180) provided on November 24, 2020.