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

 
We decided that the Plan has to pay for drug testing provided on October 31, 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 G0482 and 80307 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; 15-21 drug class(es), including 
metabolite(s) if performed. 
 
We find that CPT code G0482 is supported in the medical record. Specifically, the lab report clearly shows that 
15-21 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 drug testing provided on October 31, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for injections on February 7, 2022. 
 
You asked the Plan to waive the copayment for injections. You say that you would like to appeal the cost share. 
The Plan denied your request. The Plan says the cost share 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 20% 
coinsurance for injections. The total allowed amount of the injections is $392.48, resulting in a coinsurance 
amount of $78.50. 
 
You have been asked to pay a 20% coinsurance for injections. Injections fall within the Medicare Part B 
Prescription Drugs 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 injections on 
February 7, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the drug testing provided on October 25, 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 G0482 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; 15-21 drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0482 is supported in the medical record. Specifically, the lab report clearly shows that 
15-21 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 October 25, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that the requested hospital bed is 
medically necessary due to paraplegia. The Plan denied your request. The Plan says the requested hospital bed 
is not covered by Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (E0265).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
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 the 
service is not medically necessary. Our physician reviewer found you received oral medications, had stable 
vital signs and your lungs were clear. You were at a standby assist to contact guard assist level for functional 
mobility including gait to 12 feet x 2. You do not require skilled nursing or therapy services on a daily basis. 
You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing 
facility 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 skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve a skilled nursing facility (SNF) admission. You say that staying in the 
hospital will keep your health from improving as you need physical and occupational therapy to gain back your 
strength. The Plan denied your request. The Plan says based on Medicare guidelines and the information we 
have about your condition you don't meet all the requirements. 
 
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 a skilled nursing facility (SNF) 
admission. Our reviewer says that you were admitted to the facility with syncope and anemia. Our physician 
reviewer found based on the documentation provided, you do not qualify for SNF coverage. You do not have 
daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional 
nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an 
inpatient basis in a SNF setting. Your care needs, custodial care and intermittent, can, as a practical matter, be 
provided at a lower level of care. 
 
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 skilled nursing facility (SNF) admission. have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Buprenorphine Hcl. 
 
You asked the Plan to pre-approve Buprenorphine Hcl. You say that the medication is necessary. The Plan 
denied your request. The Plan says there are in-network providers that are able to provide these services. 
Therefore, coverage criteria have not been met. 
 
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 pre-approve Buprenorphine Hcl.  
 
Benefits for Buprenorphine Hcl 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140), 
intraoral - periapical first radiographic image (D0220) and extractions, erupted tooth requiring removal of bone 
and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) provided 
February 9, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the limited oral exam, periapical x-ray and dental extractions. You say that you 
were not aware there were providers that would accept your insurance and needed the extractions done. The 
Plan denied your request. The Plan says these services are not covered when provided OON. 
 
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 limited 
oral exam, periapical x-ray and dental extractions when the services are provided by a participating provider.  
We looked at the file and Medicare rules. In this case the services were provided OON. Based on this 
information, we decided that the Plan's rules for coverage of the limited oral exam, periapical x-ray and dental 
extractions have not been met. Therefore, we decided that the Plan does not have to pay for the limited oral 
evaluation - problem focused (D0140), intraoral - periapical first radiographic image (D0220) and extractions, 
erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal 
flap if indicated (D7210) provided February 9, 2022, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF is not 
medically necessary. 
 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 the SNF admission. Our reviewer says 
that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not require 
skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service 
criteria for an inpatient basis in a skilled nursing facility 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 the SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xalkori. 
 
You asked the Plan to pre-approve Xalkori. You say that the medication is necessary. The Plan denied your 
request. The Plan says there are in-network providers that are able to provide these services. Therefore, 
coverage criteria have not been met. 
 
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 pre-approve Xalkori.  
 
Benefits for Xalkori 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) destruction of the 
intraosseous basivertebral nerve. 
 
You asked the Plan to pre-approve RFA of the basivertebral nerve. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says the denial of authorization for this service is 
correct, because there are no specific studies demonstrating that the basivertebral nerve is the source of the 
enrollee's pain. 
 
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 RFA of the basivertebral nerve. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has no measure of bone density and is older than any of the 
published studies' age ranges. This is still considered an experimental/investigational procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of RFA of the basivertebral nerve have not been met. Therefore, we decided that 
the Plan does not have to pre-approve radiofrequency ablation (RFA) destruction of the intraosseous 
basivertebral nerve.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the lab testing described by codes 87481, 87500, 87641, 87653, 87801, 
and 87640. We decided that the Plan does not have to pay for the lab testing described by codes 87651 and 
87150.  
 
You asked the Plan to pay for the lab testing. You say that this testing was medically necessary. The Plan says 
that most of the codes that were appealed are not appealable, so they are not addressed. The two other codes 
remain denied on appeal due to NCCI edits. 
 
We decided that the Plan has to pay for the lab testing described by codes 87481, 87500, 87641, 87653, 
87801, and 87640.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
These codes were denied on December 23, 2021, for requested information not being received. That such 
information was received as an appeal request would not exempt the code from an appeal determination. Since 
the Plan forfeited the opportunity to provide a valid denial rationale, we find that the denial is not substantiated. 
Therefore, we decided that the Plan has to pay for the lab testing described by codes 87481, 87500, 87641, 
87653, 87801, and 87640.  
 
We also decided that the Plan does not have to pay for the lab testing described by codes 87651 and 
87150. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Code 87651 and 87150 are Column 2 codes in relation to 87801 and 87500, respectively. This claim has not 
been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing 
described by codes 87651 and 87150. 
 
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 pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need transportation 
to get to appointments. The Plan denied your request. The Plan says once your 24 one-way trips have been 
used, no additional trips can be approved. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Healthy Groceries meals benefit. 
 
You asked the Plan to pre-approve Healthy Groceries. You say that you are requesting this benefit. The Plan 
denied your request. The Plan says the denial of authorization for this service is correct, because the Plan was 
unable to verify that you have any of the health conditions that would qualify you for coverage of the Healthy 
Groceries benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 the Healthy Groceries meals benefit. 
have been met. No supporting documentation has been submitted by your treating physician to show that you 
have one of the conditions that qualify for special supplemental benefits for the chronically ill, or that your 
condition would be made worse by not having  or would benefit from receiving assistance with  healthy 
groceries. The Plan made several requests to your treating physician to obtain supporting medical records, but 
did not receive any. Therefore, we have not received sufficient information to determine that you meet the 
criteria for the Healthy Groceries benefit. Therefore, we decided that the Plan does not have to pre-approve the 
Healthy Groceries meals benefit.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left knee genicular radiofrequency ablation. 
 
You asked the Plan to pre-approve left knee genicular radiofrequency ablation. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have not been met. 
 
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 left knee genicular radiofrequency 
ablation. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found this is considered an experimental/investigational 
procedure whose role in the treatment of knee osteoarthritis is still being evaluated. Therefore, the request is 
deemed not medically reasonable or 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 left knee genicular radiofrequency ablation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve left knee genicular radiofrequency ablation.