Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Transcutaneous Electrical Nerve Stimulation (TENS) device.

You asked the Plan to pre-approve the requested device. You say that you suffer from diabetic neuropathy, and has arthritis in the spine and both knees. The Plan denied your request. The Plan says you are not being treated for a covered condition for the device.

The Plan follows Medicare rules. Medicare rules say that a TENS device is only covered under certain medical indications.

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 requested device. Our physician reviewer found that you suffer from diabetic neuropathy on both legs, arthritis in her spine, and both knees. You also report severe pain that goes through your back, and sciatic nerve pain. The records provided do not show that your condition is covered for the requested TENS device. You do not have acute postoperative pain and are not in an approved clinical study. Your medical conditions do not meet the criteria for the TENS device. Therefore, based on the rules and records provided, the requested device is not medically reasonable and necessary to treat your condition.

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 requested device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Transcutaneous Electrical Nerve Stimulation (TENS) device.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on August 28, 2019.
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 according to the claims data available at the time of the review, the plan was unable to discover any evidence of an established relationship between the member and the ordering physician.
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 the denied codes is: CPT 80307: Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service HCPCS G0483: 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 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 services at issue in this case were not supported by the medical records. Our physician reviewer found the records provided do not support an established relationship with the patient and the ordering physician. The records provided do not support the codes 80307 and G0483 as the order was incomplete. 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 provided to the enrollee on August 28, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the crown (D2740) provided on December 21, 2019.You asked the Plan to reimburse you for the crown. You say that you were told that you would be responsible for a total of $445 for the crown. You also say that the provider has not contacted you back on scheduling a follow up appointment to fix the crown.The Plan denied your request. The Plan says this claim was paid appropriately.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, crowns (D2740) are covered under this benefit and you are responsible for a $195 copay.You also agreed to pay the lab fee in addition to your copayment.Therefore, we decided that the Plan does not have to reimburse you for the crown (D2740) provided on December 21, 2019.Your complaint about the unsatisfactory work and overcharges from the provider is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye exam and refraction received on February 17, 2020.You asked the Plan to pay for the services. You say that you did not consent to a medical exam, and you thought you were only getting a free routine eye exam.The Plan denied your request. The Plan says the clam was processed appropriately.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 $45 copayment for eye exams. You have been asked to pay a $45 copayment for the services. The services falls within the eyeexams 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. Additionally, the additional charges for the refraction cannot be covered, as this service is not covered.Therefore, we decided that the Plan does not have to pay for an eye exam and refraction received on February 17, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 and G0482 provided on
December 4, 2019.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the services billed are not supported by the 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.
We find that CPT codes 80307 and G0482 are not supported in the medical record. Specifically, the
documentation does not support evidence of an established relationship between the enrollee and the ordering
physician. Based on this information, we decided that Medicare rules for coverage of the drug testing have not
been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded 80307 and
G0482 provided on December 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodic oral evaluation, first intraoral periapical x-ray, each additional intraoral periapical x-ray, and prophylaxis provided on February 26, 2020 by an OON provider.You asked the Plan to pay forthe periodic oral evaluation, intraoral periapical x-rays, and prophylaxis. You say that this was emergency care for a broken tooth. You also say that you are unemployed and do not know how to pay the provider.The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that your policy has no coverage for services provided by an OON provider.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for 100% of the cost for dental services received from an OON provider. The Plan also reviewed their contact history and has no record of a provider verification call from you prior to the services being rendered.Therefore, we decided that the Plan does not have to pay forthe periodic oral evaluation, first intraoral periapical x-ray, each additional intraoral periapical x-ray, and prophylaxis provided onFebruary 26, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98942) rendered by
the out of network (OON) provider on November 13, 2019.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network
provider, without prior authorization.
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 provider in this case is not a network provider with the Plan. The Plan has network providers available
who can provide the service 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 this service. Therefore, we decided that the Plan does not
have to pay for the chiropractic manipulative treatment (98942) rendered by the out of network (OON)
provider on November 13, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for the outpatient mental health visits provided on November 21, 2018 and December 28, 2018.
You asked the Plan to reduce the copayments for the outpatient mental health visits. You say that you would like the copayment reduced to $20. You say you did not know mental health practitioners have a $40 copayment. 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 Medicare-covered individual therapy session. You have been asked to pay a $40 copayment for each of the outpatient mental health visits. The outpatient mental health visits fall within the "Outpatient Mental Health 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 reduce the copayments for the outpatient mental health visits provided on November 21, 2018 and December 28, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided by an out-of-network provider on
March 2, 2020.
You asked the Plan to pay for the visit. You say that this should be paid for. The Plan denied your request. The
Plan says the provider is not in-network, and there is no authorization on file.
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 has network providers
available who can provide 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 an office visit provided by an out-of-network
provider on March 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 and G0482 provided on July
30, 2019.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the services billed are not supported by the 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.
We find that CPT codes 80307 and G0482 are not supported in the medical record. Specifically, the
documentation submitted did not include a valid physician order/lab requisition or medical records (signed by
the ordering physician) stating exactly what tests were to be performed. The submitted laboratory requisition
indicates that custom toxicology profile R093 panel was requested. The submitted documentation does not
itemize what tests are included in this panel. Based on this information, we decided that Medicare rules for
coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for
the drug testing coded 80307 and G0482 provided on July 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Image Guided Radiation Therapy (IGRT) (G6002,
77295, and 77338).
You asked the Plan to pre-approve IGRT. You say that this is the appropriate treatment. The Plan denied your
request. The Plan says this is 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 pre-approve IGRT. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found for radiation in the palliative setting, IGRT could be considered medically necessary when it is necessary
to escalate the dose, particularly when using very high dose per fraction, or when critical normal tissues
abutting the target necessitate daily image guidance to allow minimal planning margins to spare the normal
tissue. In this case, the intent is clearly palliative, in a patient with widespread disease, and there is no plausible
rationale for what benefit IGRT would afford.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IGRT have not been met. Therefore, we decided that the Plan does not have to
pre-approve Image Guided Radiation Therapy (IGRT) (G6002, 77295, and 77338).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 panel rendered on October 22, 2019.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claim was not billed correctly.The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure code 81479.The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay for the Guardant360 panel rendered on October 22, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance ride provided on March 1, 2020.
You asked the Plan to waive the copayment for the ambulance ride. You say that you did not need to be transported by ambulance. You say you were told your insurance would take care of the transportation. 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 $200 copayment for each covered, one-way ambulance trip by ground or water. You have been asked to pay a $200 copayment for the ambulance ride. The ambulance ride falls 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 the ambulance ride provided on March 1, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to lower the copayment foreye surgery (66984) provided on January 16, 2020 and January 29, 2020.You asked the Plan to lower the copayment foreye surgery. You say that this charge is excessive and you were quoted a lower cost-share by your doctor.The Plan denied your request. The Plan says these services processed 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 $445 copayment for outpatient surgery provided at an ambulatory surgical center. You have been asked to pay a $445 copayment for each eye surgery. 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 lower the copayment foreye surgery (66984) provided on January 16, 2020 and January 29, 2020
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a ForSeeHome device (0379T).
You asked the Plan to pre-approve the ForSeeHome device. You say that you would like reconsideration
because Medicare paid for this device last year and you would like to continue to be able to use it. The Plan
denied your request. The Plan says that this device is not medically necessary.
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 ForSeeHome device. Our reviewer
says that the requested items/services are considered medically reasonable and necessary in this case. Our
physician reviewer found patients with early age-related macular degeneration (AMD) and/or a family history
of AMD should be encouraged to assess their own VA using monocular vision testing and have scheduled
dilated eye examinations for detecting the intermediate stage of AMD.
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 ForSeeHome device have been met. Therefore, we decided that the Plan has
to pre-approve a ForSeeHome device (0379T).
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 medical services provided on October 10, 2019 by an out
of network (OON) provider.
You asked the Plan to pay for the ENT services. You say that you would like reconsideration because you were
not made aware of the prior approval and in-network requirements when you went in for the services. The Plan
denied your request. The Plan says there are network providers within the time and distance standards set forth
by Medicare that are available to provide the services in appeal.
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 has network providers
available who can provide 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 medical services provided on October 10, 2019
by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe insertion of an intrauterine device (IUD) (58300 and J7297) provided on January 17, 2020.You asked the Plan to pay forthe insertion of an IUD. You say that this was medically necessary.The Plan denied your request. The Plan says this isnot covered.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 58300 and J7297 are not supported in the medical record. Specifically, both of these codes has a status code of N. Medicare does not cover these services. Based on this information, we decided that Medicare rules for coverage of the insertion of an IUD have not been met.Therefore, we decided that the Plan does not have to pay forthe insertion of an intrauterine device (IUD) (58300 and J7297) provided on January 17, 2020