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

We decided that the Plan does not have to pay for the drug testing coded G0483 provided on January 6, 2020.
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. In this case, the CPT Code Manual definition of code G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed. We find that CPT code G0483 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. 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 G0483 provided on January 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on December 4, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on December 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 11, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services 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 physician's services provided on October 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you an additional amount for eyeglasses provided on
December 4, 2020, and December 20, 2020.
You asked the Plan to reimburse you an additional amount for the eyeglasses. You say that this provider had
eyeglasses that you liked, and the cost was reasonable. The Plan denied your request. The Plan says the
eyewear benefit covers only one pair of eyeglass lenses and frames each year.
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.
We looked at the file and the Plan's rules. The file shows that the Plan reimbursed you the correct amount for
one pair of eyeglasses. Therefore, we decided that the Plan does not have to reimburse you an additional
amount for eyeglasses provided on December 4, 2020, and December 20, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a surgical placement of implant body: endosteal implant (D6010) for tooth #5.
You asked the Plan to pre-approve the endosteal implant. You say that you would like to appeal this service. The Plan denied your request. The Plan says that implants are covered to replace only one tooth in the same part of your mouth. The Plan also says that the records show your dentist has asked to replace more than one tooth in this part of your mouth with an implant.
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. The Plan covers the endosteal implant when the services are medically necessary and reasonable. 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 endosteal implant. Our reviewer says that the documentation supports the criteria for coverage for an implant in area #5. Our physician reviewer found no other implant has been placed in the maxillary right quadrant and there is no documentation that another implant in this area is planned. It is my opinion that an implant in area #5 is medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the endosteal implant have been met. Therefore, we decided that the Plan has to pre-approve a surgical placement of implant body: endosteal implant (D6010) for tooth #5.
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: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on March 18, 2021.

You asked the Plan to pay for a limited oral evaluation. You say that you would like the Plan to pay. The Plan denied your request. The Plan says the service at issue is 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 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 pay for a limited oral evaluation (D0140) provided on March 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit you had with a neurologist on March 30, 2020.

You asked the Plan to waive the copayment for the neurology visit. You say that you contracted an infection in the hospital and you should not have to pay for this service. The Plan denied your request. The Plan says you were charged this copayment 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 $40 copayment for visits with a specialist. 

You have been asked to pay a $40 copayment for the neurology visit. The neurology visit falls within the visits with a specialist benefit category. This copayment applies regardless of the reason for the visit.

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 office visit you had with a neurologist on March 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the dental consultation (D9310), the incisional biopsy of soft tissue (D7286), and the pathology exam of body tissue (88307) provided on January 28, 2021.

You asked the Plan to reimburse you for the dental and pathology services. You say that your dentist suggested you see an oral surgeon for any pain that persisted longer than 2 weeks. You say that the oral surgeon suggested you have a biopsy done for a lesion on your tongue. You say that this should be covered under your health insurance rather than dental insurance because it is cancer. You also say that you understand the provider was out of network, but some of the services should be covered. The Plan denied your request. The Plan says the services in this case are dental in nature. The Plan says that routine dental services are not covered by Medicare. The Plan says that the providers in this case are out of network. The Plan says that services performed out of network are not covered either. The Plan also says that the services could have been provided in network.

Medicare generally does not cover dental services. The Plan follows the same rule. Medicare rules also say that plans can require enrollees to get care from network providers.

The services you are asking the Plan to reimburse you 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 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 reimburse you for these items/services. Additionally, the record shows that you signed a treatment plan acknowledging that the services would not be covered by insurance. Therefore, we decided that the Plan does not have to reimburse you for the dental consultation (D9310), the incisional biopsy of soft tissue (D7286), and the pathology exam of body tissue (88307) provided on January 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services you received on February 18, 2021.
You asked the Plan to pay for the chiropractic services. You say that you were told that you would only have a copayment. The Plan denied your request. The Plan says these services are not covered when provided by a chiropractor.
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 are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the chiropractic services you received on February 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services coded 99291 provided on October 22, 2020.
You asked the Plan to pay for the critical care services. 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. In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes.
We find that CPT code 99291 is not supported in the medical record. Specifically, the documentation submitted did not support a critical care visit of 30-74 minutes was performed on the billed date of service. The documentation did not include the time spent providing this service. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services coded 99291 provided on October 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator.

You asked the Plan to pre-approve a home ventilator. You say that this item is medically necessary for your condition. The Plan denied your request. The Plan says the coverage criteria for this device have 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. 

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 home ventilator. Our reviewer says that the requested equipment is not medically reasonable and necessary. Our physician reviewer found this patient has obstructive sleep apnea and likely obesity hypoventilation syndrome, although this is not confirmed with an arterial blood gas. Bi-level positive airway pressure (BiPAP) equipment is the appropriate treatment for this. There is no evidence of BiPAP failure. Medicare does not cover a home ventilator when used as BiPAP.

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 home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar traction device purchased on December 6, 2020.
You asked the Plan to pay for the lumbar traction device. You say that you bought this because you were in
terrible pain and this was the only way you could get relief. The Plan denied your request. The Plan says that
prior authorization was not obtained.
The Plan must follow Medicare rules. The rules state that Medicare payment cannot be made to a supplier who
is not enrolled in the Medicare Program.
The purchase was not made with a supplier who is enrolled in the Medicare program. Therefore, we decided
that the Plan does not have to pay for the lumbar traction device purchased on December 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the specialist office visit provided on November 14, 2019.

You asked the Plan to waive the copay for the specialist visit. You say that the services were for a tumor that could have become cancerous. The Plan denied your request. The Plan says the claim 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 $20 copay for services in a specialist office. 

The file shows that you received services from a urology specialist. You have been asked to pay a $20 copay for the services provided. The services fall within the physician 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 copay for the specialist office visit provided on November 14, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for non-emergency ambulance services (A0428) provided on January 7, 2021.
You asked the Plan to waive the copayment for non-emergency ambulance services. You say that the hospital arranged for the transportation and you should not be made responsible for payment. The Plan denied your request. The Plan says the correct copayment was 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 $250 copayment for ambulance services. You have been asked to pay a $220.99 copayment for non-emergency ambulance services. The service at issue falls within the ambulance services benefit category.
Since the Allowed Amount for this service is less than the required copayment of $250, you have been asked to pay only $220.99. 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 non-emergency ambulance services (A0428) provided on January 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided by a participating provider on March 31, 2021.

You asked the Plan to waive the copayment for an MRI. You say that someone gave you the vaccine in the wrong spot. You say that you were unable to lift your arm. You say that you should not have to pay for this. 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 $135 copayment for outpatient diagnostic tests/in-network/MRI. 

You have been asked to pay a $135 copayment for an MRI. The correct copayment has been applied to the diagnostic radiology services that were provided. An MRI falls within the outpatient diagnostic tests/in-network/MRI 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 an MRI provided by a participating provider on March 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the medical eye exam you received on December 15, 2020.

You asked the Plan to waive the copayment for the medical eye exam. You say that you believe you should only have one copayment per year for medical eye exams and that this exam should be considered a routine exam for which there is no copayment. The Plan denied your request. The Plan says you were charged this copayment 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 $30 copayment for medical eye exams. 

The records show that on this date of service you had a medical eye exam, not a routine exam. You pay a copayment for each medical eye exam you have. You have been asked to pay a $30 copayment for the medical eye exam. 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 medical eye exam you received on December 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedure provided on February 18, 2021.

You asked the Plan to pay for the preventive procedure. You say that you were advised by the Plan that this
treating provider was in-network. The Plan denied your request. The Plan says this service is not covered.

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 pay for the
preventive procedure provided on February 18, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to reimburse you for the gastroenterology office visit provided on December 28, 2020.
You asked the Plan to reimburse you for the gastroenterology office visit. You say that the Plan should reimburse you. The Plan denied your request. The Plan says that the provider did not request prior authorization and you are not responsible for the charges.
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 were referred for the gastroenterology office visit by a contract provider. The file does not show that the Plan provided notice that the gastroenterology office visit would not be covered. Under Medicare rules, this means the gastroenterology office visit is considered approved by the Plan. Therefore, we decided that the Plan has to reimburse you for the gastroenterology office visit provided on December 28, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the dermatology visit you had on January 13, 2021.

You asked the Plan to waive the copayment for the dermatology visit. You submitted a pathology report but you did not explain why you were appealing this copayment. The Plan denied your request. The Plan says you were charged this copayment 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 $40 copayment for visits to a specialist's office. 

You have been asked to pay a $40 copayment for the dermatology visit. The dermatology visit falls within the visits to a specialist's office 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 dermatology visit you had on January 13, 2021.