Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physician services provided by a participating provider on February 15, 2020.
You asked the Plan to waive the copayment for physician services. You say that you do not agree with this 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 $40 which is less than your copayment amount of $50 for physician services. Physician services 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 physician services provided by a participating provider on February 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0483) provided on August 6, 2020.
You asked the Plan to pay for drug testing. You say that this is a covered service. The Plan denied your request.
The Plan says this was not billed correctly.
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 drugspecific
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 submitted medical
records do not document that at least 22 drug classes were tested. Based on this information, we decided that
Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not
have to pay for drug testing (G0483) provided on August 6, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the cleaning (D1110) provided on November 23, 2020.
You asked the Plan to pay for the dental service. You say that you purchased the enhanced dental coverage. You say that you have receding gums and have been working on your dental hygiene for more than thirty years to save your teeth. You say that you need to get a professional cleaning 3 times a year to stay ahead of this condition. You also say that you do not need to pay for the enhanced dental plan if it does not cover this third cleaning. The Plan denied your request. The Plan says that 2 cleanings are covered per calendar year. The Plan says that the frequency limit for this service has been exceeded.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. We find that you denied payment based on frequency limitation. There was no documentation in the case file which substantiates this claim. Without documentation showing that this service has been paid according to the benefits, we cannot determine if the frequency limitation has in fact been exceeded. Therefore, we decided that the Plan has to pay for the cleaning (D1110) provided on November 23, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology services provided on
September 2, 2020.
You asked the Plan to pay for the diagnostic radiology services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.
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 diagnostic radiology services. 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 diagnostic radiology services provided on September 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided from June 5, 2020, through September 11, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.
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 physician's services. 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 from June 5, 2020, through September 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the four crowns (D2740 x4) provided on July 15, 2020.
You asked the Plan to pay for the crowns. You say that you would like these services to be covered. The Plan denied your request. The Plan says this service is not a covered benefit 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 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 four crowns (D2740 x4) provided on July 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the group 3 power wheelchair (K0861).
You asked the Plan to pre-approve the group 3 power wheelchair. You say that this device is medically necessary. The Plan denied your request. The Plan says you no longer have the motor functioning to operate power wheelchair and that a manual wheelchair would serve your needs.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 group 3 power wheelchair. Our reviewer says that the requested group 3 power wheelchair is not medically reasonable and necessary. Our physician reviewer found you are a 31-year-old male with muscular dystrophy. The documentation indicates that you have a mobility deficit that impairs MRADLs in the home and is not ameliorated by a walker, cane, manual wheelchair due to upper and lower extremity weakness. Because you have a neuromuscular disorder, you qualify for a group 3 power wheelchair. However, the documentation indicates that your power wheelchair is currently operated by your parents and that the patient is total care for all ADLs and IADLs. Therefore, the documentation does not support that the requested power wheelchair will significantly improve participation in MRADLs in the home over the recommended manual wheelchair. The DME consulting evaluation indicates it is uncertain whether a visual impairment exists that would prevent safe independent use of a mobility device. As a result, it is not clear that with adaptations to a group3 wheelchair that you will be able to safely use the requested device to participate in MRADLs in the home. 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 group 3 power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve the group 3 power wheelchair (K0861).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two abutment supported porcelain/ceramic crowns provided on November 11, 2020.
You asked the Plan to pay for the abutment supported porcelain/ceramic crowns. You say that you and the enrollee thought these services would be classified as crowns, not implants. The Plan denied your request. The Plan says these services are 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 because they are considered to be implant services. Therefore, we decided that the Plan does not have to pay for the two abutment supported porcelain/ceramic crowns provided on November 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (80053, 80061, 84443, 85025) provided December 3, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says rules for coverage were not met.
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 tests at issue in this appeal were requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for lab services (80053, 80061, 84443, 85025) provided December 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care rendered on September 18,
2020.
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 diagnosis code is not valid.
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis
code.
We looked at the file and Medicare rules. The file shows that the claim was not billed with a valid primary
diagnosis code. 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 subsequent hospital care
rendered on September 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for lab work provided by an out-of-network provider on September 13, 2020.
You asked the Plan to waive the deductible for lab work. You say that you would like this processed as in-network. You say that you up to your summer cottage because of the rise in Covid-19 cases. The Plan denied your request. The Plan says the correct deductible amount has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $500 deductible for outpatient diagnostic tests/out-of-network/labs. The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient diagnostic tests/out-of-network/labs. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible for outpatient diagnostic tests/out-of-network/labs. This cost sharing is a contractual obligation that had not been met at the time lab work was received on September 13, 2020. The total amount you are being asked to pay is $334.54. Therefore, we decided that the Plan does not have to waive the deductible for lab work provided by an out-of-network provider on September 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on November 19, 2020 and November 30, 2020.
You asked the Plan to pay for the office visit (99214) and Application of interdental fixation device for conditions other than fracture or dislocation, includes removal (21110). You say that you were not aware the provider does not accept your healthcare plan. The Plan denied your request. The Plan says the provider opted out of Medicare therefore no payment can be made.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the dental services provided on November 19, 2020 and November 30, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the diagnostic mammogram and ultrasound provided on December 11, 2020.
You asked the Plan to waive the deductible for the diagnostic mammogram and ultrasound. You say that the second mammogram was requested because of the original findings. You say that you should not have to pay the cost of this mammogram. The Plan denied your request. The Plan says the deductible applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that your deductible is $750. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost of your covered services. The item or service you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $750 deductible applies to diagnostic imaging. This cost sharing is a contractual obligation that had not been met at the time the diagnostic mammogram and ultrasound were received on December 11, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the diagnostic mammogram and ultrasound provided on December 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ophthalmology visit you had on September 30, 2020.
You asked the Plan to waive the copayment for the ophthalmology visit. You say that you were seen by another eye specialist on June 13, 2020, who you say was unable to diagnose your condition. You then saw this ophthalmologist on September 30, 2020. You do not believe you should have to pay a copayment for both visits. 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 $45 copayment for visits with a specialist. You have been asked to pay a $45 copayment for the ophthalmology visit. The ophthalmology 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 ophthalmology visit you had on September 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0482 provided on August 10, 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 G0482 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; 15-21 drug class(es), including metabolite(s) if performed. We find that CPT code G0482 is not supported in the medical record. Specifically, the documentation does not support 15-21 drug classes to support this code. 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 G0482 provided on August 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D0274) and the core buildup (D2950).
You asked the Plan to pay for the crown and core build up. You say that you needed to get your crown fixed. The Plan denied your request. The Plan says the correct cost share was applied to the claim.
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 either not among those covered under this benefit or in excess of this benefit. Specifically, the Plan does not cover core buildup (D2950). In addition, you have been asked to pay the correct amount for the crown (D0274). The Plan contract specifically states that benefits received out-of-network are subject to any in-network benefit maximums, limitations, and/or exclusions, and you may be billed by the out-of-network provider for any amount greater than the payment made by the Plan to the provider. Therefore, we decided that the Plan does not have to pay for the crown (D0274) and the core buildup (D2950).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation rendered on June 20, 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 filed timely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for these services was not filed until December 10, 2020. A valid Waiver of Liability was not received until January 15, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the psychiatric diagnostic evaluation rendered on June 20, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve extracorporeal shockwave lithotripsy for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says that there is no documentation of active symptoms.
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 services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found a standard of kidney stone treatment is to render a patient stone-free. The enrollee has bilateral renal calculi found by ultrasound, with the largest fragment measuring 7 mm on the left side. A patient may require multiple treatments to accomplish this goal. As such, extracorporeal shockwave lithotripsy is appropriate and indicated in this case. 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 been met. Therefore, we decided that the Plan has to pre-approve extracorporeal shockwave lithotripsy for the enrollee.