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

 
We decided that the Plan does not have to pay for emergency room services (99285) provided to the enrollee 
on March 16, 2021. 
 
You asked the Plan to pay for the services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says a modifier was not used to represent the services as separate and distinct. 
 
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 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. Counseling and/or coordination of care with 
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature 
of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the review indicates that the 
evaluation and treatment did not meet the guidelines for CPT 99285, as the the presenting problems were not of high severity and did not pose an immediate significant threat to life or physiologic function. In addition, the 
medical decision-making was not of high complexity. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for emergency room services (99285) provided to the enrollee on March 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the composite filling provided February 24, 2022. 
 
You asked the Plan to pay for the composite filling. You say that you do not understand how your dental 
maximum has already been met. The Plan denied your request. The Plan says you have exhausted your dental 
benefit. 
 
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 the composite 
filling up to a $2,000 annual dental allowance. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that the full $2,000 dental 
allowance has been applied to dental services provided February 24, 2022. You have been asked to pay the cost 
of the composite filling which has exceeded your dental allowance. Therefore, we decided that the Plan does 
not have to pay for the composite filling provided February 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital services on December 
20, 2021. 
 
You asked the Plan to waive the copayment for outpatient hospital services. You say that you would like to 
appeal the cost share. The Plan denied your request. The Plan says the copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 
copayment for outpatient hospital services.  
 
You have been asked to pay a $150 copayment for outpatient hospital services. Outpatient hospital services 
falls within the outpatient hospital services benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for outpatient hospital services on December 20, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the drug testing provided on November 14, 2018. 
 
You asked the Plan to pay for the drug testing. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says that the documentation submitted does not 
support the services 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. 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 supported in the medical record. Specifically, the lab report clearly shows that 
22+ drug classes were tested in this case. Please note, we counted the classes based on the separately billable 
tests from the CPT Handbook. Additionally, the Plan has not forwarded any evidence to support why CPT code 
80307 is not eligible for payment. It is the burden of the Health Plan to substantiate their denial with evidence. 
In this case, the Plan's denial has not been substantiated so we must find in your favor. Also, the record 
indicates that this provider was directed by the Plan to not obtain records. With this direction, it is inappropriate 
for the Plan to deny these services based on the physician signature. Based on this information, we decided that 
Medicare rules for coverage of the drug testing have been met. Therefore, we decided that the Plan has to pay 
for the drug testing provided on November 14, 2018.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided by an out-of-
network provider on February 22, 2022. 
 
You asked the Plan to pay for periodontal maintenance. You say that you would like the Plan to pay for this. 
The Plan denied your request. The Plan says the rendered dental service is not a covered benefit. 
 
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. Therefore, we decided that the Plan does not have to pay for 
periodontal maintenance (D4910) provided by an out-of-network provider on February 22, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the drug testing provided on March 8, 2019. 
 
You asked the Plan to pay for the drug testing. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says that the documentation submitted does not 
support the service 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. In this case, the CPT Code Manual definition of 
code G0480 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; 1-7 drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0480 is supported in the medical record. Specifically, the lab report clearly shows that 
1-7 drug classes were tested in this case. Please note, we counted the classes based on the separately billable 
tests from the CPT Handbook. Also, the record indicates that this provider was directed by the Plan to not 
obtain records. With this direction, it is inappropriate for the Plan to deny these services based on the physician 
signature. Based on this information, we decided that Medicare rules for coverage of the drug testing have been 
met. Therefore, we decided that the Plan has to pay for the drug testing provided on March 8, 2019.  
 
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 cardiac risk assessment genetic screening testing provided to 
the enrollee on November 23, 2021. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider does not mention any need for hereditary cardiovascular genetic testing. 
 
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 testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found Medicare Part B covers cardiovascular disease screening tests when ordered by the physician who is 
treating the beneficiary for the purpose of early detection of cardiovascular disease in individuals without 
apparent signs or symptoms of cardiovascular disease. The provider does not mention any need for hereditary cardiovascular genetic testing and the testing was not reported as completed during this visit, even thought the 
appellant states the lab sample was collected in the physician's office. The review has determined that the 
services at issue in this case were not medically reasonable and necessary. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for cardiac risk assessment genetic screening testing provided to the enrollee on November 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional unit of fluoroscopic guidance provided to the 
enrollee on September 14, 2021. 
 
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 there is no additional documentation or confirmation to support an additional study, which was 
billed and remains denied. 
 
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 77002 is "Fluoroscopic guidance for needle placement 
(eg, biopsy, aspiration, injection, localization device) (List separately in addition to code for primary 
procedure)." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the provider reported two units for 
fluoroscopic guidance for needle placement. The Medically Unlikely Edits (MUE) for this service is 1. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for an additional unit of fluoroscopic guidance provided to the enrollee on September 14, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that the patient needs inpatient, skilled therapies to 
work to progress back to her prior level of function (PLOF). The Plan denied your request. The Plan says based 
on Medicare guidelines, the Skilled Nursing Facility (SNF) services you are requesting do not meet the 
requirements for approval. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 pre-approve SNF services. Our reviewer says that 
this does not meet criteria. Our physician reviewer found the enrollee does not have daily skilled nursing needs 
that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does 
not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient 
basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that this device is medically 
necessary. The Plan denied your request. The Plan says coverage rules have not been met. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Notes were limited to a single set of leg measurements. This is insufficient to support a four week 
trial. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the drug testing provided on October 15, 2018. 
 
You asked the Plan to pay for the drug testing. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says that the documentation submitted does not 
support the service 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. In this case, the CPT Code Manual definition of 
code G0480 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; 1-7 drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0480 is supported in the medical record. Specifically, the lab report clearly shows that 
1-7 drug classes were tested in this case. Please note, we counted the classes based on the separately billable 
tests from the CPT Handbook. Also, the record indicates that this provider was directed by the Plan to not 
obtain records. With this direction, it is inappropriate for the Plan to deny these services based on the physician 
signature. Based on this information, we decided that Medicare rules for coverage of the drug testing have been 
met. Therefore, we decided that the Plan has to pay for the drug testing provided on October 15, 2018.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a diagnostic service consultation (D9310) provided by a 
participating provider on February 22, 2022. 
 
You asked the Plan to pay for a diagnostic service consultation. You say that these services are required by 
your dentist. The Plan denied your request. The Plan says the requested service is not a covered benefit. 
 
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. Therefore, we decided that the Plan does not have to pay for a 
diagnostic service consultation (D9310) provided by a participating provider on February 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and an extraction 
(D7140), provided by an out-of-network provider on February 7, 2022, to February 18, 2022. 
 
You asked the Plan to pay for a comprehensive oral evaluation and an extraction. You say that you would like 
the Plan to pay for this. The Plan denied your request. The Plan says these services have been processed 
correctly. 
 
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. The Plan covers a 
comprehensive oral evaluation and an extraction when the services are medically necessary and reasonable.  
 
We looked at the file and Medicare rules. The rendering dentist is out-of-network. Based on this information, 
we decided that the Plan's rules for coverage of a comprehensive oral evaluation and an extraction have been 
met and processed correctly according to the out-of-network benefit rules. Therefore, we decided that the Plan 
does not have to pay for a comprehensive oral evaluation (D0150), and an extraction (D7140), provided by an 
out-of-network provider on February 7, 2022, to February 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of left knee. 
 
You asked the Plan to pre-approve an MRI. You say that the enrollee needs an MRI of the left knee. The Plan 
denied your request. The Plan says the medical records do not show that the enrollee meets criteria for 
coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 an MRI. Our reviewer says that the 
MRI is not medically necessary. Our physician reviewer found that based on the medical records provided 
there is no documentation that supports that the requested MRI scan of the left knee meets Medicare criteria for 
medically reasonable and necessary. Provided records do not document the duration of the enrollee's knee pain 
or any relieving or exacerbating factors except pain with walking and unstable gait. No knee examination is 
documented, and no recent plain radiographs of the knee are provided. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve magnetic resonance imaging (MRI) of left knee.