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

 
We decided that the Plan does not have to pay for the comprehensive metabolic panel (80053) thyroid 
stimulating hormone (TSH) (84443) and complete blood count automated test 85025) provided April 18, 2022. 
 You asked the Plan to pay for the laboratory services. You say that you ask for reconsideration of your claims 
for payment based on the current federal guidelines for COVID-19 testing and reimbursement. The Plan denied 
your request. The Plan says The services are not authorized because, they are not a Medicare benefit for the 
diagnoses listed on the claim and are done for screening purposes 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the laboratory services, 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 comprehensive metabolic panel (80053) thyroid stimulating hormone (TSH) (84443) and complete 
blood count automated test 85025) provided April 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99222) provided on May 18, 2022. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this service is not separately payable. 
 
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 99222 is not supported in the medical record. Specifically, this service is included in the 
global surgery package of code 43235 which was billed for the same date of service. Based on this information, 
we decided that Medicare rules for coverage of the physician services have not been met. Therefore, we 
decided that the Plan does not have to pay for physician services (99222) provided on May 18, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia services for lower intestinal endoscopic procedures (00811) 
billed for date of service September 15, 2022. 
 
You asked the Plan to pay for anesthesia services. You say that the services at issue have been billed correctly. 
The Plan denied your request. The Plan says that rules for payment have not been met. 
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the case record does not contain a clear and specific denial rationale 
or an explanation of how possible claim errors might be corrected. It is the Plan's responsibility to substantiate 
its denial with evidence. In this case, the Plan's denial has not been substantiated, so we must find in your 
favor. Therefore, we decided that the Plan has to pay for anesthesia services for lower intestinal endoscopic 
procedures (00811) billed for date of service September 15, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a TMJ appliance. 
 
You asked the Plan to pre-approve a TMJ appliance. You say that the requested item is a medical necessity for 
you. The Plan denied your request. The Plan says that the requested item cannot be provided under the medical 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers treatment for TMJ syndrome only 
when the condition or symptom is medical in nature. The treatment must also be medically reasonable and 
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 a TMJ appliance. Our reviewer says 
that the requested item is medically reasonable and necessary in this case. Our physician reviewer found that 
your diagnosis is degenerative joint disease, right TMJ and possible disc displacement, and left TMJ. An 
orthotic dental appliance repositions the structures of the TMJ (condyle) to allow repositioning of the disc and 
reduce impingement of nerves. This is primarily a medical condition not related to the dental structures (teeth 
and supporting structures of the teeth). 
 
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 TMJ appliance have been met. Therefore, we decided that the Plan has to pre-
approve a TMJ appliance.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic mammography provided on 
July 27, 2022. 
 
You asked the Plan to waive the copayment for the diagnostic mammography. 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 $50 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay a $50 copayment for the diagnostic mammography. This service falls within the 
outpatient diagnostic tests and therapeutic services and supplies 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 a diagnostic mammography provided on July 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (22+ classes) provided to the enrollee 
on August 25, 2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the number of definitive urine drug classes requested are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that based on the medical records provided there is no documentation that 22 or more drug classes were 
reasonable to be tested in this case. The provided records do not document the results of a screening drug test 
that were presumptively positive, or the results of the screen were negative, and this negative finding was 
inconsistent with the patient's medical history or there was no presumptive test available, locally and/or commercially, as required by the Local Coverage Determination (LCD) - Drug Testing (L34645). 
 
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 drug testing services (22+ classes) provided to the enrollee on August 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for take-home supplies of methadone (code G0278) provided on 
August 1, 2022. 
 
You asked the Plan to pay for take-home supplies of methadone. The Plan denied your request. The Plan says 
individual providers cannot bill for OTP services. Payment is not allowed for this claim because it does not 
meet the opioid treatment program criteria for payment. Per CMS, we can only pay opioid treatment program 
claims for SAMHSA certified provider. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare Part B coverage is available for 
outpatient Opioid Treatment Program services provided by hospitals, CAHs, and Free-Standing Opioid 
Treatment Program facilities. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of take-home supplies of methadone have not been met. Therefore, we decided that the Plan does not 
have to pay for take-home supplies of methadone (code G0278) provided on August 1, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a low dose computed tomography (LDCT) scan for lung 
cancer screening on August 30, 2022. 
 
You asked the Plan to pay for the requested LDCT scan. You say that you would like to request reconsideration 
of the denied claim. The Plan denied your request. The Plan says the service is a covered benefit, but the 
enrollee has exceeded limits set in the subscriber agreement. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 We reviewed the file and the Medicare rules. We find that you previously received a covered LDCT scan on 
March 9, 2022; therefore, this LDCT exceeded the once annually coverage limit. Therefore, we decided that 
the Plan does not have to pay for a low dose computed tomography (LDCT) scan for lung cancer screening on 
August 30, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 75726 billed for date of service July 12, 
2022.  
You asked the Plan to pay for procedure code 75726. You say that multiple exams were performed on this date 
of service, so this should not be denied as bundled. The Plan denied your request. The Plan says payment for 
code 75726 is bundled into payment for code 37244. 
 
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 75726 is a column II code to column I code 37244. Code 75726 was 
billed with modifier -59 to bypass the edit. However, review of the documentation does not show that a visceral 
angiogram that was separate and distinct from the embolization procedure was performed. The code definition 
for 37244 includes all "radiological supervision and interpretation, intraprocedural roadmapping, and imaging 
guidance necessary to complete the intervention". As the angiographies that are documented were all 
performed to complete the intervention, the use of modifier -59 is not supported. 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 75726 billed for date of service July 12, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the enrollee does not meet Medicare guidelines for an 
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 that the documentation does not support necessity for admission to an IRF due to lack 
of acute medical events or medical complexity and lack of skilled rehabilitation nursing needs. The enrollee has chronic tetraplegia and was dependent and it is unlikely that the enrollee will improve with 
IRF care. While the enrollee may benefit from physical therapy, and occupational therapy, the enrollee's 
rehabilitation needs can be provided in a lower intensity and alternate 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the IRF admission and services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on August 14, 2022. 
 
You asked the Plan to pay for the emergency department visit. You say that the services were provided after 
you fell on the stairs and broke glass with your elbow and suffered a deep cut. You say that you went to an 
emergency room and received x-rays to verify if there were broken bones and you stitches. The Plan denied 
your request. The Plan says although services were rendered in an emergency setting, the provider is registered 
as a Student In An Organized Health Care, therefore the claim does not qualify for payment due to provider not 
being officially licensed. 
 
The Plan must follow Medicare rules. Medicare rules say that a supplier means a physician or other 
practitioner, or an entity other than a provider that furnishes health care services under Medicare.   
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the emergency department visit have not been met. Therefore, we decided that the Plan does not 
have to pay for an emergency department visit provided on August 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the heart with 
coronary calcium scoring (75571). 
 
You asked the Plan to pre-approve a heart CT with coronary calcium scoring. You say that the requested 
service is a medical necessity for you. The Plan denied your request. The Plan says rules for coverage have not 
been met.  
The Plan must follow Medicare rules. Medicare rules say that the requested service is never covered for 
screening, i.e., in the absence of signs, symptoms or disease. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a heart CT with coronary calcium scoring have not been met. Specifically, the medical records do 
not support that you display signs, symptoms or disease that warrant the provision of the requested service. 
Therefore, we decided that the Plan does not have to pre-approve a CT scan of the heart with coronary calcium 
scoring (75571).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (procedure code 99285) provided 
to the enrollee on November 19, 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 diagnosis codes do not support this procedure. 
 
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 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. Counseling and/or coordination of care with 
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature 
of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the review has determined that 
the records did not support that the medical decision making was of high complexity. The records did not 
support that the presenting problems were high severity. The records did not support that the presenting 
problems were posing an immediate significant threat to life or physiologic function. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for emergency room services (procedure code 99285) provided to the enrollee on November 19, 
2021.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to waive the copayment for an antibody stain laboratory procedure. We 
decided that the Plan does not have to waive the copayment for an ultrasound and an injection.  
 
You asked the Plan to waive the copayment for an antibody stain laboratory procedure, an ultrasound, and an 
injection provided on September 23, 2022.. You say that this should be considered a screening. The Plan says 
that these services were processed correctly. 
 
We decided that the Plan has to waive the copayment for an antibody stain laboratory procedure.  
 
The Plan follows Medicare rules. Medicare rules say that a plan must disclose to its enrollees in clear, accurate 
terms all cost sharing information. Your contract with the Plan says that enrollees must pay a $0 copayment for 
in-network Medicare-covered laboratory tests. 
 
The Plan says you must pay a $20 copayment for an antibody stain laboratory procedure. Based on the Plan 
contract, however, you cannot be asked to pay more than $0 for in-network Medicare-covered laboratory tests. 
Therefore, we decided that the Plan has to waive the copayment for an antibody stain laboratory procedure. 
 
We also decided that the Plan does not have to waive the copayment for an ultrasound and an injection. 
 
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 $70 
copayment for in-network Medicare-covered diagnostic advanced imaging, such as ultrasounds and a 20% 
coinsurance for in-network Medicare-covered Part B drugs. 
 
You have been asked to pay a $70 copayment for an ultrasound, which falls into the diagnostic advanced 
imaging benefit category, and a $1.48 coinsurance (7.41 allowed amount x 20% = $1.48). 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 an ultrasound and an injection. 
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76700 billed for date of service August 17, 
2022. 
 You asked the Plan to pay for procedure code 76700. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76700 is bundled into payment for 
code 93976. 
 
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 76700 
is a column II code to column I code 93976. 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 procedure code 76700 billed for date of service August 17, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tramadol HCL. 
 
You asked the Plan to pre-approve Tramadol HCL. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested drug is not a covered benefit. 
 
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 Tramadol HCL.  
 
Benefits for Tramadol 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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray of the pelvis provided on January 22, 2022. 
 
You asked the Plan to pay for an x-ray of the pelvis. You say that the submitted records support this service 
was also needed. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on January 5, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for an x-ray of the pelvis 
provided on January 22, 2022.