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

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on March 11, 
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 Healthcare Common Procedure Coding System (HCPCS) code G0482 remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that 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. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for drug testing services provided to the enrollee on March 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services (99214), provided on December 1, 
2021. 
 
You asked the Plan to pay for the chiropractic care. You say that the service should be covered. The Plan 
denied your request. The Plan says this is not a covered service. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the chiropractic services (99214), provided on December 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on November 24, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed based 
on the medical documentation. The Plan denied your request. The Plan says this claim has not been billed in 
accordance with Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that 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. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on November 24, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on October 19, 
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 the denied codes remain not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that 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. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for drug testing services provided to the enrollee on October 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on December 
30, 2021. 
 
You asked the Plan to pay for the dental service. You say that you have been having issues with your teeth 
recently. You say that you need to see your dentist more than twice per year as a result. The Plan denied your 
request. The Plan says 2 oral exams are covered per year. The Plan also says that the frequency limit has been 
exceeded. 
 
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 and 2 oral exams are covered per year, 
the frequency limit has been exceeded. The record shows that the Plan paid for oral exams that you received on 
April 1, 2021, and July 9, 2021. Therefore, we decided that the Plan does not have to pay for the limited oral 
evaluation (D0140) provided on December 30, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided October 27, 2021, to 
November 2, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that inpatient care was medically 
necessary. The Plan denied your request. The Plan says that there is no documentation that meets the criteria 
for inpatient admission or an extended stay, as pain management is not an indication for either. 
 
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. 
 
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 supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the review has determined that the record showed that at the time of inpatient admission 
the admitting physician reasonably expected that the patient's necessary hospital care (including earlier 
emergency department and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided October 27, 2021, to November 2, 2021.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on September 17, 2021. 
 
You asked the Plan to pay for the ambulance service. You say that you thought you were having a heart attack 
when you called the ambulance. You say that you were feeling better by the time they arrived. You also say 
that you feel you should not be responsible for this because you saved everyone money. The Plan denied your 
request. The Plan says since there was no transport provided, there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on September 17, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.  
 
 
 
 
 
  
 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport, (A0998) provided on September 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core build up (D2950), retainer crowns (D6740 x 2, 
D6750 x 4), pontics (D6245 x 2, D6240 x 2), and periapical x-rays (D0220, D0230 x 2) provided on January 
13, 2022. 
 
You asked the Plan to pay for the dental services. You say that the dental office advised that everything was 
approved. You say that you advised you could not afford to go over your plan's benefit amount. You also say 
that you do not understand why you are receiving these bills. The Plan denied your request. The Plan says the 
claims processed correctly. 
 
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 and 1 periapical x-ray is covered per 
calendar year, the frequency limit has been exceeded. The record shows that the Plan paid for 1 periapical x-ray 
that was performed on January 13, 2022. Additionally, the core build up, retainer crowns, and pontics are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core 
build up (D2950), retainer crowns (D6740 x 2, D6750 x 4), pontics (D6245 x 2, D6240 x 2), and periapical x-
rays (D0220, D0230 x 2) provided on January 13, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy (PT) services provided on August 5, 
2021, by an out of network (OON) provider. 
 
You asked the Plan to pay for the PT services. You say that the services were provided in good faith to the 
enrollee. You also say that the services were medically necessary. The Plan denied your request. The Plan says 
prior authorization was not obtained before the services were rendered to the enrollee. 
 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 the physical therapy (PT) services provided on 
August 5, 2021, by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided to the enrollee on January 22, 
2022. 
 
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 a physician certificate statement certifying medical necessity requirements was not provided. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 services. Our reviewer says that the 
services at issue in this case were not medically reasonable or necessary. Our physician reviewer found the 
enrollee's vitals were stable, and did not require oxygen or other treatment during transport. The documentation 
does not support that other means of transport (such as stretcher van) were contraindicated for this patient. The 
documentation does not support that the patient needed the expertise, services and lifesaving and life-sustaining 
equipment that only a fully-equipped ambulance can provide for safe transport on the denied date of service. 
The documentation does not support that the ambulance transport on 1/22/22 was medically reasonable and 
necessary for the patient. 
 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for ambulance services provided to the enrollee on January 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuous intraoperative neurophysiology monitoring 
(95941) provided on December 2, 2021. 
 
You asked the Plan to pay for continuous intraoperative neurophysiology monitoring. You say that the service 
at issue was billed correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 95941 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code 95941 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of continuous intraoperative neurophysiology monitoring have not been met. Therefore, we decided 
that the Plan does not have to pay for continuous intraoperative neurophysiology monitoring (95941) provided 
on December 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight Psychotropic test (81479) provided December 
1, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that based on the peer-reviewed literature and a 
technology assessment, Medicare has been covering the test as reasonable and medically necessary since 
October 24, 2014. The Plan denied your request. The Plan says this service does not meet Medicare criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 We looked at this the file, and Medicare rules. 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 the GeneSight Psychotropic test (81479) provided December 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on September 
21, 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 Healthcare Common Procedure Coding System (HCPCS) code G0483 (1 unit) remains not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that 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. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for drug testing services provided to the enrollee on September 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection procedure for sacroiliac joint (27096) provided 
on June 24, 2021.  You asked the Plan to pay for the injection procedures for sacroiliac joint (27096). You say that CPT code 
27096 should be billed on two lines with RT and LT to show the service was done bilaterally. You say that the 
claim denied incorrectly per MUE guidelines, and the claim should be processed correctly. The Plan denied 
your request. The Plan says CPT code 27096 has exceeded the billable units. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 27096 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the 
injection procedures for sacroiliac joint (27096) have not been met. Therefore, we decided that the Plan does 
not have to pay for the injection procedure for sacroiliac joint (27096) provided on June 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the determination of refractive state (92015) provided 
December 6, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the eye refraction. You say that the provider was in-network for your visit so you 
do not understand what the denial is for. The Plan denied your request. The Plan says this service is not 
covered because it was provided OON. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when rendered by a provider in the Plans third party vision vendors 
network. 
 
We looked at the file and the Plan's rules. In this case the eye refraction was not provided by a routine vision 
provider. Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not 
been met. Therefore, we decided that the Plan does not have to pay for the determination of refractive state 
(92015) provided December 6, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee's needs can be safely met at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. The patient 
appears to be more stable and improving and should only require short-term additional acute care services that 
can safely be completed at the current facility until more appropriate for a lower level of care. The patient does 
not require services at the LTACH that are not already available at the current facility. Our physician reviewer 
found that the enrollee's condition does not meet Medicare criteria for LTACH services. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room hospital services provided 
from November 22, 2021, through November 25, 2021. 
 
You asked the Plan to waive the copayment for emergency room hospital services. The Plan denied your 
request. The Plan says the member is responsible for a $120 copayment for emergency room services. This 
claim was processed correctly according to the members 2021 Evidence of Coverage. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $120 copayment for emergency care.  
 
 
 The enrollee has been asked to pay a $120 copayment for emergency room hospital services. Emergency room 
hospital services falls within the emergency care benefit category. This means that the enrollee has been asked 
to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the 
enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for emergency room hospital services provided from November 22, 2021, through  
November 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from May 
17, 2021, to May 21, 2021. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the DRG was updated.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 562 (FRACTURE, SPRAIN, STRAIN AND 
DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC). 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 services. Our reviewer says that the services at issue in this case 
were not supported by the medical records. Our physician reviewer found the reviewed documentation 
supported an admission for displaced spiral fracture of shaft sustained after a fall. Even though respiratory 
failure is documented, supporting medical record documentation was not found within the record. Although the 
provider documented respiratory failure, reasonable support within the health record must be present for that 
diagnosis. DRG 563: FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, 
PELVIS AND THIGH WITHOUT MCC is the appropriate DRG.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from May 17, 2021, to May 21, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are too weak to return home and need 
recommended level of service. The Plan denied your request. The Plan says the stay is not medically necessary 
based on SNF criteria. 
 
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 care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you do not meet severity of illness or intensity 
of service criteria for an inpatient basis in a 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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.