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

 
We decided that the Plan does not have to pay for an extraction, erupted tooth or exposed root (elevation and/or 
forceps removal) tooth #'s 2, 5 (D7140), and extraction, erupted tooth requiring removal of bone and/or 
sectioning of tooth and including elevation of mucoperiosteal flap if indicated tooth #'s 6, 11, 14 (D7210) 
provided on July 18, 2022. 
 
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says these services 
are not covered under the benefit package. 
 
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 pay for an 
extraction, erupted tooth or exposed root (elevation and/or forceps removal) tooth #'s 2, 5 (D7140), and 
extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of 
mucoperiosteal flap if indicated tooth #'s 6, 11, 14 (D7210) provided on July 18, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve high sensitivity C-reactive protein (hsCRP) testing (86141) 
provided May 14, 2021. 
 
You asked the Plan to pre-approve the laboratory services. You say that please find the attached document and 
reconsider the claim for payment. The Plan denied your request. The Plan says that does not meet Medicare 
NCD/LCD criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 laboratory services. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is has a history of rheumatoid arthritis (RA), essential hypertension, 
hyperlipidemia, overweight, and prediabetes. Based on the enrollees conditions placing them at moderate to 
high risk for cardiovascular events, it is reasonable to measure hsCRP to further evaluate inflammation-
associated risk. Also, based on the enrollees RA diagnosis, measuring CRP periodically is standard to evaluate 
the degree of inflammation related to the arthritis. Based on the provided documentation, this request for high 
sensitivity C-reactive protein (hsCRP) testing 86141 is supported in the medical records and medically 
necessary for this patient's conditions.  
 
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 laboratory services have been met. Therefore, we decided that the Plan has 
to pre-approve high sensitivity C-reactive protein (hsCRP) testing (86141) provided May 14, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services (G0483) provided on August 5, 
2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code 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 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/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; 22 or 
more drug class(es), including metabolite(s) if performed". 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the records do not show that 
22 or more drug classes were tested on the date of services in question. 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 the drug testing services (G0483) provided on August 5, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services on April 16, 
2022. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you want to appeal the 
amount being charged. 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 $90 
copayment for Emergency care. Emergency care refers to services that are furnished by a provider qualified to 
furnish emergency services, and needed to evaluate or stabilize an emergency medical condition. 
 
You have been asked to pay a $90 copayment for emergency room services. This item/service falls within the 
Emergency care 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 emergency room 
services on April 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81225, 81226, 81227) provided on April 7, 
2022. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
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 the lab services have been met. No 
clinical documentation was provided to support the testing. Only lab results were provided for review. Therefore, we decided that the Plan does not have to pay for lab services (81225, 81226, 81227) provided on 
April 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that the requested CGM is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for the requested CGM. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
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 CGM. Our reviewer says that the 
enrollee does not meet criteria for the requested CGM. Our physician reviewer found the record indicates that 
the enrollee has diabetes. The record indicates that the enrollee is receiving four injections of insulin daily that 
are not adjusted based upon the glucose monitor testing results. The elements of the coverage criteria are not satisfied. The requested service is not 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 a CGM have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a continuous glucose monitor (CGM).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay provided on March 
23, 2022, to March 28, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that it wasnt your choice to be 
released the first time so this should be covered. 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 $345 
copayment for Inpatient hospital care. 
 
You have been asked to pay a $345 copayment for inpatient hospital stay. This item/service falls within the 
Inpatient hospital care 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. You have been asked to pay a total of $1,725 ($345 x 5 days) copayment for your inpatient 
hospital stay. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital 
stay provided on March 23, 2022, to March 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for injections on May 06, 2022.

You asked the Plan to waive the coinsurance for injections. You say that you want to appeal the amount being charged. 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 20% coinsurance for Medicare-covered Part B Chemotherapy drugs and other Part B drugs. Covered drugs include drugs that usually aren't self-administered by the patient and are injected or infused while you are getting physician, hospital outpatient, or ambulatory surgical center services. The provider billed in the amount of $4,320 and the allowed amount is $1,001.86. $1,001.86 x 20% = $200.37. Therefore, results in the total cost sharing amount of $200.37.




You have been asked to pay a 20% coinsurance for injections. This item/service falls 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 coinsurance for injections on May 06, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the clinical documentation does show that the enrollee has complex functional 
deficits with history of Traumatic brain injury (TBI), left upper limb contracture, spasticity, however, there is no documented etiology to current symptoms thus would not be able to state that the enrollee would benefit 
significantly from intensive rehabilitation. Clinical documentation does not specify etiology and there are no 
listed active comorbidities that would require continued inpatient hospitalization for close medical monitoring. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 6, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says there were network providers available. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
service 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 an office visit provided on July 6, 2022, by an out-of-network 
(OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on August 3, 2020. 
 
You asked the Plan to pay for therapy services. You say that you did not receive the enrollee's information. The 
Plan denied your request. The Plan says that the claim for the requested services was submitted untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for therapy services was not filed until August 10, 2022. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for physical therapy services provided on August 3, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cytopathology, in situ hybridization (eg, fish), urinary tract 
specimen with morphometric analysis, 3-5 molecular probes, each specimen; manual (88120) provided October 
25, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that please see notes. All lines should have been 
paid for. The Plan denied your request. The Plan says diagnosis code does not substantiate the service. There is 
no evidence to support the referring/ordering provider is/was treating the patient 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The Plan made outreach to the provider's office and confirmed that 
there was no order for genetic testing for the enrollee. Based on this information, we decided that Medicare 
rules for coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not 
have to pay for cytopathology, in situ hybridization (eg, fish), urinary tract specimen with morphometric 
analysis, 3-5 molecular probes, each specimen; manual (88120) provided October 25, 2021.
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 May 4, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you disagree with the denial. 
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 May 4, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71250 billed for date of service December 
16, 2021. 
 
You asked the Plan to pay for procedure code 71250. You say that this service is supported as billed. The Plan 
denied your request. The Plan says the payment for code 71250 is included in the payment for code 71260. 
 
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, we have confirmed that code 71250 
is a column II code to column I code 71260 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 71250 billed for date of service December 16, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance oxygen (A0422NH), and ambulance attendant 
(A0424NH) provided on July 26, 2021. 
 
You asked the Plan to pay for the ambulance supplies. You say that you want the Plan to pay for the services. 
The Plan denied your request. The Plan says no payment can be made under the physician fee schedule for 
these services. 
 
The Plan must follow Medicare rules. Medicare rules say that ambulance supplies are considered part of the 
general ambulance service and payment for them is included in the payment rate for the transport. Therefore, 
we decided that the Plan does not have to pay for ambulance oxygen (A0422NH), and ambulance attendant 
(A0424NH) provided on July 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88341, 88342, 88360 and 88381 billed for 
date of service January 10, 2022. 
 
You asked the Plan to pay for procedure codes 88341, 88342, 88360 and 88381. You say that these services 
were necessary and are supported in the medical record. The Plan denied your request. The Plan says these 
services were not billed in accordance with Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that payment is not made under the physician fee schedule for Technical Component (TC) services 
furnished in institutional settings where the TC service is bundled into the facility payment, e.g., hospital 
inpatient and outpatient settings. In addition, TC services furnished by independent laboratories to hospital 
patients are not payable by the MAC. 
 
We find that procedure codes 88341, 88342, 88360 and 88381 are physician pathology services which have 
both professional components (PC) and technical components. These services were not billed with modifier 26 
to indicate that only the professional component payment is requested. This means that payment is requested 
for both the PC and TC of these services. However, these services were provided to an enrollee who was in an 
inpatient hospital setting at the time the sample was collected, which means that the TC component is bundled 
into the facility payment. The TC portion of these services are not separately payable, and therefore these 
services are not supported as billed. Based on this information, we decided that Medicare rules for coverage of 
procedure codes 88341, 88342, 88360 and 88381 have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure codes 88341, 88342, 88360 and 88381 billed for date of service January 10, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder. 
 
You asked the Plan to pre-approve an implantable loop recorder. You say that the requested implantable loop 
recorder is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria 
for the requested implantable loop recorder. 
 
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 implantable loop recorder. Our 
reviewer says that the enrollee does not meet criteria for the requested implantable loop recorder. Our physician 
reviewer found while the enrollee has a history of atrial fibrillation, there is no documentation provided to 
suggest a history of unexplained syncope, cryptogenic stroke or any other apparent indication for an 
implantable loop recorder (ILR). In summary, there is insufficient documentation to support the medical 
necessity for insertion of an ILR in this enrollees clinical management. 
 
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 implantable loop recorder have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an implantable loop recorder.