Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy provided on August 23, 2022. 
 
You asked the Plan to pay for the psychotherapy. You say that the service should be covered. The Plan denied 
your request. The Plan says there was no documented contact with the attending/primary care physician. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy have not been met. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for the psychotherapy provided on August 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for short-latency somatosensory evoked potentials (SSEPs) 
rendered on September 20, 2022. 
 
You asked the Plan to pay for the SSEPs. You say that this was medically necessary. The Plan denied your 
request. The Plan says the use of short-latency somatosensory evoked potentials is not medically reasonable 
and necessary for intraoperative testing during carotid endarterectomy. 
 
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 SSEPs. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the enrollee underwent carotid endarterectomy (CEA). They were not suspected of 
having a situation/condition in which "any slowing of conduction through the brain and/or brainstem, spinal cord, and/or peripheral nerves is suspected. Nor were they undergoing spinal surgery for which the LCD 
supports the use of intraoperative SSEPs. 
 
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 SSEPs have not been met. Therefore, we decided that the Plan does not have 
to pay for short-latency somatosensory evoked potentials (SSEPs) rendered on September 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on August 18, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on August 
18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) provided on August 31, 2022. 
 
You asked the Plan to pay for the office visit (99214). You say that the service should be covered. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visit (99214) 
provided on August 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing (procedure code G0483) rendered on October 
13, 2022. 
 
You asked the Plan to pay for the testing. You say that this drug screening is a Medicare-covered service. The 
Plan denied your request. The Plan says the records do not show screening test results which are positive or 
inconsistent with prescription medications, dosing schedules, or history and expected results. 
 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 that the mmedical record sent by the provider shows a definitive urine drug testing panel for multiple 
drug classes was performed, but does not show  show screening test results which are positive or inconsistent 
with prescription medications, dosing schedules, or history and expected result medications, dosing schedules, 
or history and expected results. 
 
 
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 drug testing (procedure code G0483) rendered on October 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a preventive physical exam provided on October 5, 2022. 
 
You asked the Plan to pay for the preventive physical exam. You say that you have always had a separate 
annual exam with your gynecologist as part of your annual wellness checks as your primary care physician 
does not perform this service. The Plan denied your request. The Plan says you have exceeded the maximum 
benefit limit for an annual preventive physical exam. 
 
The Plan contract covers an annual preventive physical exam once every calendar year. 
 
We looked at the file and the Plans rules. The file shows that you have had two wellness exams this year and 
you have exceeded the maximum benefit limit. Therefore, we decided that the Plan does not have to pay for a 
preventive physical exam provided on October 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulation (G0283) provided from October 7, 
2022, through October 26, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
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 services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the electrical stimulation (G0283) provided from October 7, 2022, 
through October 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by the requested tertiary 
level of care provider. 
 
You asked the Plan to pre-approve an office visit to be provided by the requested tertiary level of care provider. 
You say that a tertiary level of care is medically necessary. The Plan denied your request. The Plan says the 
requested office visit is not medical necessary for a tertiary level of care as community providers available. 
 
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 pre-approve an office visit to be provided by the 
requested tertiary level of care provider. Our reviewer says that the requested office visit to be provided by a 
tertiary level of care provider is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that your medical condition and management do not require a tertiary level of care and the 
documentation indicates that you have been referred to and set up with an appointment with a provider in the 
community that confirmed can manage your condition.  
 
 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 office visit to be provided by the requested tertiary level of care provider 
have not been met. Therefore, we decided that the Plan does not have to pre-approve an office visit to be 
provided by the requested tertiary level of care provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services rendered on July 6, 2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says this procedure was not appropriate for this clinical situation. 
 
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that molecular syndromic infectious disease pathogen identification panel testing is not appropriate for 
this clinical situation. The Medicare criteria cited above have not been met.  
 
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 laboratory services rendered on July 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy-duty power wheelchair (K0824) and a lead 
battery (E2365). 
 
You asked the Plan to pre-approve the heavy-duty power wheelchair (K0824) and lead battery (E2365). You 
say that you never received a scooter. The Plan denied your request. The Plan says that you received the same 
or similar PMD on October 4, 2021. 
 
The Plan must follow Medicare rules. Medicare rules say that durable medical equipment cannot be replaced 
when the reasonable useful lifetime of the equipment is less than five years. 
 
We looked at the file and Medicare rules. The record shows you received a power mobility device on October 
4, 2021, and the device has not reached its reasonable useful lifetime of five years. Therefore, we decided that 
the Plan does not have to pre-approve a heavy-duty power wheelchair (K0824) and a lead battery (E2365).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for Medicare Part B drugs and intravenous 
(IV) infusions provided from September 13, 2021, to March 13, 2022. 
 
You asked the Plan to waive the cost sharing for the Part B drugs and IV infusions. You say that you were not 
notified of the change in your benefits from 2021 to 2022. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Part B drugs. Your contract also says that you must pay a $275 copayment for preferred 
hospital services.  
 
You have been asked to pay up to 20% coinsurance for the Part B drugs. These items/services fall within the 
Medicare Part B drugs benefit category. You are responsible to pay up to a $275 copayment for each IV 
infusion. However, you are being asked to pay the allowed amount for each infusion. These items/services fall 
within the outpatient hospital services benefit category. 
 
Date of Service Code Allowed Amount Coinsurance Copayment 
September 13, 2021 96365   $50 
September 13, 2021 J1569 $453.25 $90.65  
September 13, 2021 J1569 $1,812.98 $362.60  
September 14, 2021 96365   $50 
September 14, 2021 J1569 $453.25 $90.65  
September 14, 2021 J1569 $1,812.98 $344.52  
September 15, 2021 96365   $50 
September 16, 2021 96365   $50 
February 11, 2022 96365   $199.59 
February 11, 2022 96366   $78.09 
February 11, 2022 J1569 $2,660.02 $532.00  
February 12, 2022 96365   $199.59 
February 12, 2022 96366   $78.09 
February 12, 2022 J1569 $2,660.02 $532.00  
February 13, 2022 96365   $199.59 
February 13, 2022 96366   $78.09 
February 13, 2022 J1569 $2,660.02 $532.00  
March 11, 2022 96365   $199.59 
March 11, 2022 96366   $78.09 
March 12, 2022 96365   $199.59 
March 13, 2022 96365   $199.59 
 
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 cost sharing for Medicare Part B drugs and intravenous (IV) infusions 
provided from September 13, 2021, to March 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the screening tests (80053, 82043, 82607, 80061, 83036, 
84426, 8443) provided on August 24, 2022. 
 You asked the Plan to pay for the screening tests. You say that these services were medically necessary. The 
Plan denied your request. The Plan says services provided for screening purposes are not covered. 
 
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. 
 
The test at issue in this appeal, the screening tests, was requested solely for screening purposes. Medicare does 
not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for 
the screening tests (80053, 82043, 82607, 80061, 83036, 84426, 8443) provided on August 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services rendered on September 26, 2022. 
 
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 procedure was not appropriate for this clinical situation. 
 
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that urine polymerase chain reaction (PCR) amplification techniques raise considerable concerns 
regarding contamination from one specimen to another, creating the potential for false-positive results. The 
clinical interpretation of PCR results may also be challenging. Amplification of organisms representing latent 
infection or colonization cannot be distinguished from active, clinically significant infections.  Additionally, 
PCR may amplify fragments of nucleic acids, representing dead microorganisms, thus further clouding the 
clinical interpretation. Finally, specificities, sensitivities, and positive and negative predictive values of PCR 
have not been reported in large groups of patients for many of the microorganisms. 
 
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 laboratory services rendered on September 26, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI), of any joint of the 
upper extremity; without contrast material(s), followed by contrast material(s) and further sequences (73223). 
 
You asked the Plan to pre-approve this service. You say that the requested service is medically necessary. The 
Plan denied your request. The Plan says the requested service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of this service have been met. Therefore, 
we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI), of any joint of the 
upper extremity; without contrast material(s), followed by contrast material(s) and further sequences (73223).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for needle electromyography and nerve conduction study rendered on 
October 7, 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 that the records do 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 
the denied codes is: 
 
CPT 95886: 
 
Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve 
conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three 
or more nerves or four or more spinal levels (List separately in addition to code for primary procedure) 
 
CPT 95909: 
 
Nerve conduction studies; 5-6 studies 
 
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 supported by the medical records. Our reviewer found that in terms of CPT 95886, the technical 
report cites lower EMG (electromyography) had recording sites of abductor hallucis, gastroc, rectus femoris, 
tibialis anterior, and vastus medialis. This demonstrated that spinal levels S1, L5, and L2-4 were recorded. In 
terms of CPT 95909, the technical report cites nerve conduction studies (5-6 studies) were performed with 
stimulation sites of L3, L4, and L5 bilaterally. This corroborated that six studies were performed. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
needle electromyography and nerve conduction study rendered on October 7, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis (D1110) provided on November 4, 2022. 
 
You asked the Plan to pay for the dental services. You say that these services are medically necessary because 
the enrollees health is declining. The Plan denied your request. The Plan says your benefit for the requested 
item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 1, 2022, and 
May 3, 2022. Therefore, we decided that the Plan does not have to pay for prophylaxis (D1110) provided on 
November 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an urgent care visit provided on May 13, 
2022. 
 
You asked the Plan to reduce the copayment for an urgent care visit. You say that you should be charged for a 
primary care provider copayment rather than an urgent care visit. The Plan denied your request. The Plan says 
this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
copayment for urgently needed services. 
 
You have been asked to pay a $45 copayment for an urgent care visit. This item/service falls within the 
urgently needed 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 reduce the copayment for an urgent 
care visit provided on May 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endosteal implant, custom fabricated abutment, and 
abutment supported crown (D6010, D6057, D6058). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within your dental benefits. 
 
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 pre-approve an 
endosteal implant, custom fabricated abutment, and abutment supported crown (D6010, D6057, D6058).