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

We decided that the Plan does not have to pay for the unlisted ambulance service (A0999) provided October 26, 2019.
You asked the Plan to pay for the unlisted ambulance service. You say that this fee is for services provided by the fire engine that responded to my medical needs. You were released on scene and taken home. Please reconsider the denied claim. The Plan denied your request. The Plan says payment is made only if the ambulance provider provides transportation to the nearest appropriate facility that can provide care.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on October 26, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the unlisted ambulance service (A0999) provided October 26, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to adjust the coinsurance for the therapeutic, prophylactic, or diagnostic injection (96372) and the denosumab injection (J0897) provided on October 2, 2019. 
 
You asked the Plan to adjust the coinsurance for these services. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says the coinsurance has been applied correctly to the Medicare Part B drugs provided. 
 
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 Part B covered drugs.  
 
You have been asked to pay a $877.72 copayment ($4,435.62 allowed amount x 20% coinsurance) for the Medicare Part B drugs provided. 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 adjust the coinsurance for the therapeutic, prophylactic, or diagnostic injection (96372) and the denosumab injection (J0897) provided on October 2, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation, first intraoral 
periapical x-ray, bitewing x-ray, extraction, and inhalation of nitrous oxide/analgesia provided on April 1, 
2020. 
 
You asked the Plan to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, 
bitewing x-ray, extraction, and inhalation of nitrous oxide/analgesia. The Plan denied your request. The Plan 
says you were not eligible for benefits. The Plan also says that your dental coverage was termed on March 31, 
2020 due to the Plan not having received payment for your plan premium in time. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. The record shows you were advised that if the Plan did not receive payment for your plan 
premium by March 31, 2020, your preventive dental and comprehensive dental would not be covered 
beginning April 1, 2020. The documentation shows that your premiums payments were not received in full by 
March 31, 2020. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral 
evaluation, first intraoral periapical x-ray, bitewing x-ray, extraction, and inhalation of nitrous oxide/analgesia 
provided on April 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 98943 provided from November 6, 2019 to November 18, 2019.
You asked the Plan to pay for CPT code 98943. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services at issue billed with CPT code 98943 are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for CPT code 98943 provided from November 6, 2019 to November 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a 
participating provider on January 15, 2020. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you feel like this cost 
should be included with your surgery copayment. The Plan denied your request. The Plan says the correct 
copayment has been applied. 
 
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 physician/practitioner services/in-network/specialist.  
 
You have been asked to pay a $50 copayment for a specialist office visit. Since a specialist office visit was 
provided, the correct copayment has been applied. A specialist office visit falls within the 
physician/practitioner services/in-network/specialist 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 specialist office visit provided by a participating provider on January 15, 2020.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve core buildup services (CPT D2950). 
 
You asked the Plan to pre-approve the core buildup services. You say that a complete workup was completed 
and the enrollee expressed severe pain on the upper right side of her mouth. You say that tooth #3 showed 
decay, compromising tooth cuspid integrity and causing hypersensitivity. You say that the services requested 
are necessary in order to build back tooth structure. The Plan denied your request. The Plan says the service 
which remains in dispute is not a covered benefit under Medicare or the Plan. 
 
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, 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 core 
buildup services (CPT D2950).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for outpatient mental health care provided to the enrollee on 
March 17, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 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 outpatient mental health care provided to the enrollee on March 17, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for drug testing services (CPT 80307 and HCPCS G0483) 
provided to the enrollee on July 18, 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 the documentation submitted did not include a valid physician order/lab requisition or medical 
records (signed by the ordering physician); therefore the billed code cannot be verified. 
 
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, qualitative; any number of devices or procedures, by 
instrument chemistry and analyzers (e.g., utilizing immunoassay [EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), 
chromatography (e.g., GC, HPLC), and mass spectrometry either with or without chromatography, (DAT, 
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 
review has determined that the records do not support the above denied codes. The records do not contain a 
valid physician order or requisition to support the denied codes 
 
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 (CPT 80307 and HCPCS G0483) provided to the enrollee on July 18, 
2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance oxygen life sustaining (A0422) BLS routine disposable supplies (A0382) provided April 8, 2019. 
 
You asked the Plan to pay for the ambulance supplies and oxygen. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says payment for oxygen and other items and services provided as part of the transport are included in the payment for the ambulance transport and are not separately payable. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. Medicare does not allow for separate billing of oxygen and other items and services provided as part of the transport. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ambulance supplies and oxygen have not been met. Therefore, we decided that the Plan does not have to pay for ambulance oxygen life sustaining (A0422) BLS routine disposable supplies (A0382) provided April 8, 2019.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve occupational therapy for vision rehabilitation and sensory 
integration in the home. 
 
You asked the Plan to pre-approve the occupational therapy services. You say that the enrollee is visually 
impaired and needs the therapy being requested. The Plan denied your request. The Plan says that medical 
studies have not proven that the services being requested are helpful for treatment of macular degeneration. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 occupational therapy services. Our 
reviewer says that the criteria for coverage have been met. Our physician reviewer found the requested therapy 
is generally accepted as specific and effective therapy for the enrollee's condition. Patients who have age-
related macular degeneration (AMD) may benefit from referral to low vision specialists and visual 
rehabilitation programs, as well as the use of a variety of visual aids for increasing reading ability and mobility. 
There is documentation that demonstrates the unique skills of a professional therapist are required to safely and 
effectively provide treatment and that the services can safely and effectively be performed only by a therapist 
or under the supervision of a therapist. 
 
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 occupational therapy services have been met. Therefore, we decided that the 
Plan has to pre-approve occupational therapy for vision rehabilitation and sensory integration in the home.  
 
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: Favorable

 
We decided that the Plan has to pay for physician services provided on February 3, 2020. 
 
You asked the Plan to pay for this service. You say that you had a health issue and went to your plan physician 
for treatment. This should be covered by the Plan. The Plan denied your request. The Plan says that this type of 
exam was already billed for this year and was not eligible for payment. 
 
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. You saw your Plan physician for a women's health issue. You have no control 
over the codes submitted for payment. The Plan cannot penalize you for how the claim was billed. Under 
Medicare rules, this means this service is considered approved by the Plan. Therefore, we decided that the Plan 
has to pay for physician services provided on February 3, 2020.  
 
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 pay for the CPAP supplies (A7038, A7031, A4604, A7030) provided on February 26, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the CPAP supplies. You say that the items are medically necessary and you believed they would be covered by original Medicare. The Plan denied your request. The Plan says the items at issue are not emergent care and were not pre-authorized. There were network providers available that could have provided the equipment. 
 
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 CPAP supplies (A7038, A7031, A4604, A7030) provided on February 26, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on August 19, 2019.
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 the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on August 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
February 10, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 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 out of network physician services provided to the enrollee on February 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for out of area chiropractic care provided out of network and out 
of area from December 24, 2019 to January 3, 2020.  
 
You asked the Plan to pay for these services. You say that you were told by your physician at home to seek 
care while you were out of area. The Plan denied your request. The Plan says you did not have an actual 
referral or prior authorization submitted by your physician requesting out of area chiropractic care. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care. The Plan contract says that chiropractic services require a referral. You did not follow your Plan contract 
rules when you obtained these services. Therefore, we decided that the Plan does not have to pay for out of area 
chiropractic care from December 24, 2019 to January 3, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Coflex interspinous and/or interlaminar device 
(22867). 
 
You asked the Plan to pre-approve a Coflex interspinous and/or interlaminar device. You say that the services 
are necessary. The Plan denied your request. The Plan says medical necessity has not been established. 
Therefore, coverage criteria has not been met. 
 
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 a Coflex interspinous and/or 
interlaminar device. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the Coflex device remains experimental. 
More research is needed to show the safety and efficacy of the device. There is no documented spinal 
instability. The device is not needed. 
 
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 Coflex interspinous and/or interlaminar device have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a Coflex interspinous and/or interlaminar device 
(22867).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the colonoscopy with biopsy provided on 
February 3, 2020. 
 
You asked the Plan to waive the copayment for the colonoscopy with biopsy. You say that you feel you should 
not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan 
denied your request. The Plan says you received a colonoscopy with biopsy on the date of service at issue in 
this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.  
 
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 $350 
copayment for same day outpatient surgery (includes diagnostic "scopes" such as an endoscopy provided in an 
Outpatient Hospital Facility.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received a colonoscopy 
with biopsy provided in an outpatient hospital facility on February 3, 2020. You have been asked to pay a $350 
copayment for the colonoscopy with biopsy. The colonoscopy with biopsy falls within the Outpatient surgery 
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 colonoscopy with biopsy 
provided on February 3, 2020.