Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyeglasses (V2020, V2750, V2103) provided February 11, 
2022. 
 
You asked the Plan to pay for the eyeglasses. You say that the eyeglasses should be covered. The Plan denied 
your request. The Plan says the plan allowed amount was covered. The enrollee is responsible for the amount 
over $150. 
 
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 provides an allowance of $150 towards covered eyewear every 24 months. If the eyewear 
costs more than $150 dollars, the enrollee is responsible for the difference. 
 
We looked at the file and the Plan's rules. The plan paid the $150 allowance per the Evidence of Coverage. The 
total expense of the glasses was $398.00. The amount over $150 is the enrollee's responsibility. Based on this 
information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we 
decided that the Plan does not have to pay for eyeglasses (V2020, V2750, V2103) provided February 11, 2022.
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 February 17, 2022. 
 
You asked the Plan to pay for the ambulance response. You say that you required emergency services. The 
Plan denied your request. The Plan says this service is not covered when there is no transport. 
 
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 February 17, 2022. 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 February 17, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for drug testing provided on July 9, 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 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 July 9, 2018.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant removal for tooth #31 (D6100). 
 
You asked the Plan to pre-approve implant removal for tooth #31. You say that the service is necessary. The 
Plan denied your request. The Plan says the requested service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
implant removal for tooth #31 (D6100).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hereditary cardiovascular panel provided to the enrollee on 
July 15, 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 medical literature does not support the clinical utility of this testing in someone with an 
established history of cardiomyopathy. 
 
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 the enrollee was diagnosed with cardiomyopathy. The test is described as a genetic based cardiovascular 
risk factor screening test in which multiple genes are assessed using genomic DNA extracted from patient 
sampling. It assesses the presence of pathogenic or likely pathogenic variants in genes known to be associated 
with increased cardiac risk. It is not a diagnostic test. There is no evidence to support its role in this patient 
clinical management. In summary, the requested testing is not considered reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for a hereditary cardiovascular panel provided to the enrollee on July 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 20, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says you billed with an incorrect place of 
service on the claim. 
 
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 lab 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 lab services provided on October 20, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient skilled nursing facility (SNF) care provided from January 14, 2022, through February 4, 2022.

You asked the Plan to pay for the SNF care. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the skilled nursing facility care provided was 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 pay for the SNF care. Our reviewer says that the skilled nursing facility care provided was not medically necessary. Our physician reviewer found that based on the documentation provided, the enrollee no longer qualified for SNF coverage after January 13, 2022.  The enrollee did not have documented skilled nursing or skilled therapy needs. Daily skilled services were not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs, custodial and intermittent, as a practical matter, could have been 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 the SNF care provided have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient skilled nursing facility (SNF) care provided from January 14, 2022, through February 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) and a core buildup, including any pins 
when required (D2950). 
 
You asked the Plan to pre-approve a crown and a core buildup, including any pins when required. You say that 
you have been experiencing extreme pain form your tooth, causing you to not eat, have severe headaches, you 
lose focus and lose sleep. There has been an infection on this tooth since you had the root canal. You disagree 
with the denial and would like the Plan to cover these services. The Plan denied your request. The Plan says 
these services are covered under your benefit plan, but exceeds the maximum count allowed per period. 
 
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 a crown and a 
core buildup, including any pins when required when the services are medically necessary and reasonable.  
 
 
 
 
 We looked at the file and Medicare rules. The records show that you received a crown and a core build up on 
August 13, 2021, therefore, you have exhausted your maximum benefit for these services. Based on this 
information, we decided that the Plan's rules for coverage of a crown and a core buildup, including any pins 
when required have not been met. Therefore, we decided that the Plan does not have to pre-approve a crown 
(D2740) and a core buildup, including any pins when required (D2950).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on March 8, 
2022. 
 
You asked the Plan to waive the copayment for the lab services. You say that you have never been charged for 
lab work before. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. 
 
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 $40 
copayment for each free-standing laboratory visit.  
 
The file shows that the location code for billing was listed as a free-standing clinic. Therefore, you have been 
asked to pay $32.02, which is less than the $40 copayment for the lab services. The lab services fall within the 
Laboratory Services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for laboratory services 
provided on March 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an injection on July 22, 2021. 
 
You asked the Plan to waive the copayment for an injection on July 22, 2021. You say that this should be 
covered by the Plan. The Plan denied your request. The Plan says you are responsible to pay a $270 copayment 
for in-network surgery at an outpatient hospital. 
 
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 $270 
copayment for in-network surgery.  
 
You have been asked to pay a $235.20 copayment for an injection. An injection is considered a surgical 
service. The Plans allowance was $235.20. This means that you have been asked to pay less than your 
contracted amount 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 an injection 
on July 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with single power option. 
 
You asked the Plan to pre-approve power wheelchair and accessories. You say that this power operated 
wheelchair and accessories are medically necessary. The Plan denied your request. The Plan says the criteria 
for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not 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 power wheelchair and accessories. Our 
reviewer says that the requested wheelchair is not medically reasonable and necessary. Our physician reviewer 
found he patient has a gait abnormality that impairs participation in MRADLs in the home. The patient is able 
to ambulate with assistance but has worsening gait apraxia and poor balance. The documentation is not clear 
that the patient's caregivers are unable to propel a manual wheelchair. The documentation is not clear that the patient can safely use the requested wheelchair. The patient has decreased memory. There is no physician 
documentation of mental status other than, she is "alert." The problem solving and judgment are reported "good 
per daughter's report" but given her history of dementia it is not clear without a more detailed cognitive 
evaluation whether the patient can safely use the Group 3 wheelchair.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a group 3 power wheelchair with single power option.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services on October 19, 2021. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you want to appeal the 
amount you are being charged. The Plan denied your request. The Plan says the cost-sharing you are being 
charged 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 $300 
copayment for each Medicare-covered one-way trip via ground ambulance. Covered ambulance services 
include fixed wing, rotary wing, and ground ambulance services, to the nearest appropriate facility that can 
provide care only if they are furnished to a member whose medical condition is such that other means of 
transportation could endanger the persons health or if authorized by the plan. 
 
 
 
 You have been asked to pay a $300 copayment for ambulance services. Ambulance services fall within the 
Ambulance services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services 
on October 19, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for drug testing provided on December 27, 2018. 
 
You asked the Plan to pay for the drug testing. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says that the documentation submitted does not 
support the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code G0480 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs 
and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to 
gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, 
eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other 
universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and 
variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control 
material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all 
sources, includes specimen validity testing, per day; 1-7 drug class(es), including metabolite(s) if performed. 
  
We find that CPT code G0480 is supported in the medical record. Specifically, we find that CPT code G0480 is 
supported in the medical record. Specifically, the lab report clearly shows that 1-7 drug classes were tested in 
this case. Please note, we counted the classes based on the separately billable tests from the CPT Handbook. 
Also, the record indicates that this provider was directed by the Plan to not obtain records. With this direction, 
it is inappropriate for the Plan to deny these services based on the physician signature.. Based on this 
information, we decided that Medicare rules for coverage of the drug testing have been met. Therefore, we 
decided that the Plan has to pay for drug testing provided on December 27, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic services coded 97110, 97112, and 97530 
provided from December 7, 20221, through December 14, 2021. 
 
You asked the Plan to pay for the therapeutic services as billed. You say that you would like this claim 
reprocessed based on the medical records. The Plan denied your request. The Plan says the billed CPT codes 
are not supported by the medical documentation. 
 
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 codes  97110, 97112, and 97530 are as follows: 
97110 -  Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength 
and endurance, range of motion and flexibility  
 
97112 -  Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, 
balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities  
 
97530 -  Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve 
functional performance), each 15 minutes 
 
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 therapeutic services as billed. Our reviewer says that the 
documentation does not support the services as billed. Our reviewer found that per CPT code descriptions, 
therapy services are reported by time (15 minutes). In this case, the documentation does not support that the 
services were correctly billed as the medical records cannot verify the services were performed to match their 
CPT code descriptions. 
 
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 therapeutic services as billed have not been met. Therefore, we decided that 
the Plan does not have to pay for the therapeutic services coded 97110, 97112, and 97530 provided from 
December 7, 20221, through December 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special anesthesia service (99100) provided on July 14, 
2021.  You asked the Plan to pay for the special anesthesia service (99100). You say that the services rendered were 
based on the patient condition and was essential to their quality of health. You say that the procedure code and 
modifier were coded appropriately. The Plan denied your request. The Plan says procedure code 00731 has 
been approved and procedure code 99100 remains denied as bundled services are not eligible for separate 
payment. 
 
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 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the special anesthesia service (99100) have not been met. Therefore, we decided that the Plan does not have 
to pay for the special anesthesia service (99100) provided on July 14, 2021.