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

 
We decided that the Plan has to pay for code G0481 for date of service June 12, 2023. 
 
You asked the Plan to pay for code G0481. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says that the services billed are 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. The rules also 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. 
 
In this case, the CPT Code Manual definition of code G0481 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; 8-14 
drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0481 is supported in the medical record. Specifically, the Plan states that 13 drug 
classes were identified. The code states that 8-14 drug classes must be provided. Since 13 is within 8 to 14, the 
amount of drug classes is supported by this code. The Plan has not made reasonable and diligent efforts to 
gather and forward to us information regarding their decision to deny your request. No other denial rationale 
was provided. Based on this information, we decided that Medicare rules for coverage of code G0481 have 
been met. Therefore, we decided that the Plan has to pay for code G0481 for date of service June 12, 2023.  
 
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 pay for self-administered drugs provided on July 26, 2023, to, July 
27, 2023. 
 
You asked the Plan to pay for self-administered drugs. You say that you do not know what the appeal is for. 
The Plan denied your request. The Plan says that self-administered drugs do not fall under Medicare Part B  
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided 
on July 26, 2023, to, July 27, 2023.  
 
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on April 19, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the laboratory services by a contract provider as the file shows the sample was 
taken in a contracted facility confirmed by the case narrative. The file does not show that the plan provided 
notice that the laboratory services would not be covered. Under Medicare rules, this means the laboratory 
services are considered approved by the plan. Therefore, we decided that the Plan has to pay for the laboratory 
services provided on April 19, 2023.  
 
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 pneumatic compressor and a segmental pneumatic 
appliance for use with pneumatic compressor, full leg (E0662, E0667) to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve a pneumatic compressor and a full leg segmental pneumatic appliance to be 
provided by an OON provider. You say that the services are 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. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers.  
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a pneumatic compressor and a segmental pneumatic appliance for use with pneumatic compressor, full leg 
(E0662, E0667) to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for a routine eye examination (92014), progressive lenses 
(V2781) and frames (V2020) provided on July 13, 2023.  
You asked the Plan to reimburse for a routine eye examination (92014), progressive lenses (V2781) and frames 
(V2020). You say that the provider office took your card, made copies and did not tell you this provider is not 
in-network. The Plan denied your request. The Plan says the claim is from a provider who is not in their 
network. 
 
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 covers these services when you obtain your vision services through a Plan network 
provider. 
 
We looked at the file and the Plan's rules. The Plan rules say you must use a network provider for your 
services. Based on this information, we decided that the Plan's rules for coverage of a routine eye examination 
(92014), progressive lenses (V2781) and frames (V2020) have not been met. Therefore, we decided that the 
Plan does not have to reimburse for a routine eye examination (92014), progressive lenses (V2781) and frames 
(V2020) provided on July 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 97597 and 97598 for date of service April 
21, 2023. 
 
You asked the Plan to pay for procedure codes 97597 and 97598. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services billed are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that certain services that are provided in a skilled 
nursing facility (SNF) are included in the payment to the SNF. 
 
We looked at the file and Medicare rules. Review of the file shows that the services billed are not separately 
payable as they were provided in the SNF setting. Based on this information, we decided that Medicare rules 
for coverage of procedure codes 97597 and 97598 have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure codes 97597 and 97598 for date of service April 21, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic evaluation with medical services provided on 
September 22, 2022. You asked the Plan to pay for the diagnostic evaluation with medical services. You say that the services should 
be reviewed for payment. 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. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the diagnostic evaluation with medical services provided on 
September 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services, injection services, and drugs related 
to end-stage renal disease (ESRD) provided on June 3, 2023, to June 29, 2023. 
 
You asked the Plan to pay for the ESRD-related services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing, 
injections, and drugs. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services, injection 
services, and drugs 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, injection services, and 
drugs related to end-stage renal disease (ESRD) provided on June 3, 2023, to June 29, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services provided on June 10, 2023, by 
an out-of-network (OON) provider.  
 
You asked the Plan to pay for the physical therapy. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the services were not authorized for an OON provider and were not 
urgent or emergent.  
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 OON 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 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the physical therapy services provided on June 10, 
2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composite  three surfaces, posterior (D2393) 
provided on August 9, 2023. 
 
You asked the Plan to pay for resin-based composite. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not a covered service. 
 
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 resin-
based composite  three surfaces, posterior (D2393) provided on August 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the crown repair necessitated by restorative material 
failure (D2980). 
 
You asked the Plan to pre-approve the crown repair. You say that this service is a medical necessity. The Plan 
denied your request. The Plan says this is a non-covered service. 
 
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 the 
crown repair necessitated by restorative material failure (D2980).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with codes 87481, 87491, 
87563, 87640, 87653, 87798, 87641 and 87500 for date of service June 26, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory services billed with codes 87481, 87491, 87563, 87640, 87653, 
87798, 87641 and 87500 for date of service June 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral  comprehensive series of radiographic images 
(D0210) provided on September 6, 2023. 
 
You asked the Plan to pay for the intraoral  comprehensive series of radiographic images. You say that the 
baseline x-ray was completed for future reference. The Plan denied your request. The Plan says the services for 
D0210 are 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 services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the intraoral  
comprehensive series of radiographic images (D0210) provided on September 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the re-cement or re-bond crown (D2920) provided on 
July 6, 2023. 
 
You asked the Plan to pay more for the re-cement or re-bond crown. You say that you were traveling when 
your crown/veneer on your tooth was knocked off leaving the underlying tooth core exposed. You also say that 
you used to live in the state so you called your old dental provider for an emergency appointment and they 
were able to get an appointment for the following morning. The Plan denied your request. The Plan says you 
are responsible for any charged amount above the Plans cost-sharing amount when your services are received 
from an out-of-network provider.  
 
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. 
 You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for the re-cement or re-bond crown (D2920) 
provided on July 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466 x3). 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not 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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee had a good response with 
bilevel positive airway pressure (BIPAP). Indicating, BIPAP success, therefore, not failure. The enrollee 
should be continued on BIPAP for treatment of chronic obstructive pulmonary disease (COPD) disease, as best 
practice. The enrollee does not meet indication for a home ventilator at this time given data and documentation 
provided. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466 x3).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic parenteral drugs, two or more 
administrations, different medications (D9612) provided on June 16, 2023. 
 
You asked the Plan to pay for the therapeutic parenteral drugs. You say that you were told the procedure was 
covered now they are saying its not covered by your plan. You also say that since you were told it was covered 
you should not be liable and you are also on a fixed disability income so you can't afford to pay. The Plan 
denied your request. The Plan says this service is not a covered expense under your dental plan. 
 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 the 
therapeutic parenteral drugs, two or more administrations, different medications (D9612) provided on June 16, 
2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) provided on 
June 01, 2023, to June 13, 2023. 
 
You asked the Plan to waive the copayment for skilled nursing facility (SNF). You say that you are requesting 
a reconsideration of the denied claim. 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 $196 
copayment for Skilled nursing facility (SNF) care. 
 
You have been asked to pay a $196 copayment for skilled nursing facility (SNF). This item/service falls within the Skilled nursing facility (SNF) 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 $2,352 for the SNF stay ($196 copayment 
x 12 days = $2,352). Therefore, we decided that the Plan does not have to waive the copayment for skilled 
nursing facility (SNF) provided on June 01, 2023, to June 13, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CT scan of the thorax provided on June 30, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for the CT scan of the thorax. The Plan denied your request. The Plan says that the 
CT scan of the thorax is available in network. 
 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 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the thorax 
provided on June 30, 2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified adjunctive procedure (D9999) provided on 
April 19, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
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 
unspecified adjunctive procedure (D9999) provided on April 19, 2023.