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

 
We decided that the Plan does not have to pay for the drug testing rendered on October 28, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code G0482 is not supported. 
 
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 G0482 is definitive drug testing, 15-21 drug classes. 
 
We find that CPT code G0482 is not supported in the medical record. Specifically, the records show that 1-7 
drug classes were tested and there is a more appropriate code for these services. 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 drug testing rendered on October 28, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the myocardial perfusion imaging (78452), cardiovascular 
stress test (93017), the technetium tc-99m tetrofosmin, diagnostic, per study dose (A9502), the aminophyllin 
injection (J0280), and the regadenoson injection (J2785) rendered by the out-of-network (OON) provider on 
May 27, 2020. 
 
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 the services were rendered by an out of 
network provider, without prior authorization. 
 
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the myocardial perfusion imaging (78452), cardiovascular stress test (93017), the 
technetium tc-99m tetrofosmin, diagnostic, per study dose (A9502), the aminophyllin injection (J0280), and the 
regadenoson injection (J2785) rendered by the out-of-network (OON) provider on May 27, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the laboratory services rendered on September 22, 2020. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not separately payable. 
 
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 81401, 81402, 81403,81404, 81405, 81406 (molecular 
pathology procedures levels 1-6), and 81439 (hereditary cardiomyopathy panel). Codes 81401, 81402, 
81403,81404, 81405, and 81406 are column II codes with a modifier indicator of 1 when billed with column I code 81439. Codes 81401, 81402, 81403,81404, 81405, and 81406 were not billed with an appropriate 
modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pre-approve the 
laboratory services rendered on September 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for a comprehensive oral evaluation 
(D0150), a complete series of radiographic images (D0210), a consultation by a dentist (D9310), inhalation of 
nitrous oxide (D9230), a bone replacement graft (D7953), primary closure of a sinus perforation (D7261), a 
tooth extraction (D7210), guided tissue regeneration  (D4266), biologic materials to aid in soft and osseous 
tissue regeneration (D4265), unspecified preventative procedure (D1999) and a cone beam computed 
tomography (CT) capture (D0367) provided on May 24, 2021 by a non-participating provider. 
 You asked the Plan to pay an additional amount for dental services. You say that the dental services were 
required so that you could be cleared for a valve replacement procedure to your heart. Your provider did x-rays 
and discovered you had an infection in your sinuses. He referred you to another provider who agreed surgery 
was needed and it had to be done immediately. You paid for the dental services and are now looking for 
reimbursement. The Plan denied your request. The Plan says you are eligible for non-Medicare covered 
comprehensive dental services up to the allowable $350 per year. 
 
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 up to $350 
every year for non-Medicare covered preventative and comprehensive dental services.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of dental services have not been met. The records show that you were reimbursed the maximum 
allowed benefit of $350 for non-Medicare comprehensive dental services. Therefore, we decided that the Plan 
does not have to pay an additional amount for dental services provided on May 24, 2021 by a non-participating 
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 the enrollee meets and/or exceeds the 
criteria for admission to an LTACH and these services are medically necessary. The Plan denied your request. 
The Plan says the criteria for admission to an LTACH are not met. the enrollee is not required to discharge 
elsewhere to receive ongoing acute level care. There is no advantage in moving the enrollee from the current 
facility to an LTACH. All services that would be provided in the LTACH are being provided in the current 
acute setting which is already approved. 
 
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. Our 
physician reviewer found the enrollee is receiving the necessary acute care services at the current facility, and 
these services have not been denied. The medical record does not indicate that the enrollee requires services 
that they are not currently receiving but that would be available at the LTACH facility. The elements of the 
coverage rules are not satisfied; the requested service cannot be recommended. 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services you received on March 
27, 2021. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you are on a fixed income 
and cannot afford this copayment. The Plan denied your request. The Plan says you were charged this 
copayment correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 
copayment for ambulance services.  
 
You have been asked to pay a $275 copayment for the ambulance services. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for ambulance services you received on March 27, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug test provided on February 1, 2021. 
 
You asked the Plan to pay for the drug test. The Plan denied your request. The Plan says the records do 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 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/m. 
 
 
  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 drug test. Our reviewer says that the documentation does 
not support the service billed. Our reviewer found that the laboratory report does not document more than 22 
drug classes and would not be covered as billed. 
 
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 drug test have not been met. Therefore, we decided that the Plan does not 
have to pay for the drug test provided on February 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a repair of a partial denture base (D5611) provided on July 
12, 2021. 
 
You asked the Plan to pay for a repair of a partial denture base. You say that you cannot afford to pay the bill in 
question and were misled to believe that your dental coverage would cover the procedure. The Plan denied 
your request. The Plan says rules for payment have not been met. 
 
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 repair of 
a partial denture base (D5611) provided on July 12, 2021. Your complaint about receiving erroneous or incomplete information about your dental benefits from a 
representative of the Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance 
that must be answered by the Plan. Medicare does not permit us to make a decision about these types of 
complaints.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on March 22, 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 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, a cardiovascular risk assessment panel, 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 laboratory services rendered on March 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for apicoectomy/periradicular surgery, molar (first root) (D3425) 
bone graft in conjunction with periradicular surgery, per tooth, single site (D3428) provided April 21, 2021. 
 
You asked the Plan to pay for the dental services. You say that you had severe pain with swelling and a bad 
injection in your tooth that had to be done immediately. Your health could be harmed, and you needed oral 
surgery right away. The Plan denied your request. The Plan says these services are not covered under the Plan 
benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for apicoectomy/periradicular surgery, molar (first root) (D3425) bone graft in conjunction with periradicular 
surgery, per tooth, single site (D3428) provided April 21, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) rendered by the out-of-network 
(OON) provider on May 17, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the office visit (99213) rendered by the out-of-network (OON) provider on May 17, 
2021.
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 the enrollee needs long term care due to 
COVID-19 issues. The Plan denied your request. The Plan says the criteria for admission to an LTACH are not 
met. The enrollee has not completed their full course of care in the hospital. An LTACH does not provide a 
clinical advantage over a non-LTACH hospital. The requested transfer is not medically necessary. 
 
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. Our 
physician reviewer found in this case the enrollee was admitted with pneumonia from COVID-19 infection. 
The record indicates that the enrollee is receiving continued acute care services, and these have not been 
denied. The medical record does not indicate that the enrollee requires services that he is not already receiving 
but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The 
requested service cannot be recommended. 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided by provided from 
February 18, 2021, through February 25, 2021. 
 
You asked the Plan to pay for the self-administered drugs. You say that you don't know what the medications 
were for and you did not ask for them. You say that you don't have the funds to pay this bill and the claim 
should be reconsidered. The Plan denied your request. The Plan says self-administered drugs are not paid by 
Medicare when submitted on outpatient claims. 
  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided by provided from February 18, 2021, through February 25, 2021.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain 
rendered on May 27, 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 separately payable. 
 
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 70450 (CT head/brain) and 70496 (computed tomography 
angiography of the head). Code 70450 is a column II code with a modifier indicator of 1 when billed with column I code 70496. Code 70450 was not billed with an appropriate modifier to allow for separate payment. 
Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the 
head/brain rendered on May 27, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on 
January 26, 2021. 
 
You asked the Plan to pay for subsequent nursing facility care. The Plan denied your request. The Plan says the 
member is not eligible for the health Plan benefits while covered under hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness.  The rules say that the Plan may direct the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for subsequent nursing facility care provided on  
January 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intermittent limb compression devices (E0673, E0675) 
provided on March 16, 2021. 
 
You asked the Plan to pay for intermittent limb compression devices. You say that the items at issue were a 
medical necessity for the enrollee. The Plan denied your request. The Plan says pneumatic compression devices 
are not covered by Medicare for prevention of deep vein thrombosis. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
 
 
 The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous 
stasis ulcers. Therefore, we decided that the Plan does not have to pay for intermittent limb compression 
devices (E0673, E0675) provided on March 16, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Group 2 power wheelchair (K0823) with accessories including 
detachable armrests (E0973), an oxygen tank holder (E2208), manual swing away hardware (E1028), and a 
battery (E2365). 
 
You asked the Plan to pre-approve a Group 2 power wheelchair with accessories. You say that the requested 
items are a medical necessity for you. The Plan denied your request. The Plan says that medical necessity rules 
for the requested items have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will be covered if the patient has a mobility 
deficit that impairs their participation in MRADLs, the patient?s condition cannot be ameliorated by a walker, 
cane or manual wheelchair, and the patient is capable of safely operating the requested PMD.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Group 2 power wheelchair with 
accessories. Our reviewer says that the requested items are medically reasonable and necessary in this case. 
Our physician reviewer found that you have a personal mobility deficit that impairs participation in mobility-
related activities of daily living such as toileting, feeding, grooming, and bathing in customary locations within 
the home. Your mobility deficit cannot be helped using a walker, cane, or manual wheelchair due to extremity 
weakness, spinal pain and shortness of breath. There is documentation that you can safely operate a power 
mobility device. Based on the medical records provided, including an assessment from a physical therapist who 
is certified to have no financial relationship to the equipment vendor, there is documentation that you meet 
criteria for the requested power wheelchair coded K0823 and accessories including detachable armrests, an 
oxygen tank holder, manual swing away hardware, and a battery. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Group 2 power wheelchair with accessories have been met. Therefore, we 
decided that the Plan has to pre-approve a Group 2 power wheelchair (K0823) with accessories including 
detachable armrests (E0973), an oxygen tank holder (E2208), manual swing away hardware (E1028), and a 
battery (E2365).  
 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.