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

We decided that the Plan does not have to waive the cost shares for the physician services provided from
January 16, 2020 to March 20, 2020.
You asked the Plan to waive the cost shares for the services provided. You say that you were unaware the
provider was out-of-network. The Plan denied your request. The Plan says the claims were processed in
accordance to your benefits.
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%
coinsurance for out-of-network services.
The file shows that you received an office visit from an out-of-network provider on January 16, 2020. You
were charged a 50% coinsurance for this visit. The service falls within the physician services benefit category.
You received a Synvisc injection from an out-of-network provider on March 4 and 20, 2020. You were charged
a 50% coinsurance for each date of service. The services fall within the Medicare Part B prescription drugs
benefit category.
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 cost shares for the physician services provided from January 16, 2020 to March 20,
2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial nursing facility care services provided on February 
26, 2020 by an OON provider. 
 
You asked the Plan to pay for the initial nursing facility care services. You say that the services were ordered 
by the skilled nursing facility and primary care physician as medically necessary to avoid complications. The 
Plan denied your request. The Plan says prior authorization was not obtained. The Plan also says the enrollee 
has no OON benefits. 
 
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 initial nursing facility care services provided 
on February 26, 2020 by an OON provider.
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 
March 9, 2020. 
 
You asked the Plan to pay for this service. You say that this visit should be covered by the Plan. The Plan 
denied your request. The Plan says you 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 requested 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 March 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical mask (A4928) and non-sterile gloves (A4927), 
for the enrollee. 
 
You asked the Plan to pre-approve the items. You say that you need the gloves to clean up the enrollee. The 
Plan denied your request. The Plan says the items are not covered under Medicare or the Health Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve surgical mask (A4928) and non-sterile gloves (A4927), for 
the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergent ambulance transportation provided to the 
enrollee provided on December 16, 2019. 
 
You asked the Plan to pay for non-emergent ambulance transportation. You say that the claim should be paid. 
The Plan denied your request. The Plan says routine ambulance requires a prior authorization for dual 
advantage flex plan. The Plan states they will only cover ambulance/ambulette hospital discharge without an 
authorization. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of non-emergent ambulance transportation have not been met. The claim was denied because the 
provider  failed to notify the Plan regarding services and subsequently an authorization was not issued. 
Therefore, we decided that the Plan does not have to pay for non-emergent ambulance transportation provided 
to the enrollee provided on December 16, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient mental health care provided to the enrollee from
June 13, 2019 through June 18, 2019.
You asked the Plan to pay for inpatient mental health care. You say that the stay was medically necessary. The
Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.
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 inpatient mental health care. Our physician
reviewer found this patient did not appear to require inpatient mental health treatment beyond the date in
question as the patient was not a danger to themselves or others, no auditory hallucinations or visual
hallucinations while being cooperative with treatment. It did not appear that active treatment was taking place
beyond the date in question. It did not appear that the services were reasonably expected to improve the
patient's condition or for the purpose of diagnosis beyond the date in question. This patient was treated under
an individualized treatment plan found in the record. It did appear that the records were supervised and
evaluated by a physician. Based upon review the records provided for the admission of this patient does not
meet the criteria for continued acute inpatient mental health treatment for the dates in question of June 13, 2020
forward as this patient was not shown to be a danger to themselves or others. The patient was not showing any
auditory or visual hallucinations and was cooperative/compliant with treatment.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the
Plan does not have to pay for inpatient mental health care provided to the enrollee from June 13, 2019 through
June 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on January 30, 
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 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 physician services provided to the enrollee on 
January 30, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial nursing facility care (99306) rendered by the out of 
network (OON) provider on February 6, 2020. 
 
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 provided 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 initial nursing facility care (99306) rendered by the out of network (OON) provider on 
February 6, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the BLS non-emergency ambulance service (A0428) and 
ground mileage (A0425) provided February 18, 2020. 
 
You asked the Plan to pay for the ambulance service. You say that please see the attached paperwork for this 
claim. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all 
Medicare covered services related or unrelated to the member's terminal condition. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the BLS non-emergency ambulance service (A0428) and 
ground mileage (A0425) provided February 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a specialist visit and a CT scan provided on February 27, 2020 and March 11, 2020. You asked the Plan to waive the copayments for a specialist visit and CT scan. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $50 copayment for specialist visits. Your contract with the Plan also clearly says that you must pay a $250 copayment for CT scans. You received a specialist visit on February 27, 2020. Therefore, you are responsible to pay the $50 copayment. You received a CT scan on March 11, 2020. Therefore, you are responsible to pay the $250 copayment. The total amount you owe is: $300. You have been asked to pay the total copayment amount of $300 for a specialist visit and CT scan. A specialist 
visit falls within the physician/practitioner services, including doctor's office visits benefit category. A CT scan falls within the outpatient diagnostic tests and therapeutic services and supplies 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 copayments for a specialist visit and a CT scan provided on February 27, 2020 and March 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the core buildup (D2950). 
 
You asked the Plan to pre-approve the core buildup (D2950). You say that you have the crown authorized but 
not the material. The Plan denied your request. The Plan says the service 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 pre-approve the 
core buildup (D2950).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on November 18, 2019. 
 
You asked the Plan to pay for drug tests. You say that you have submitted a valid physician laboratory 
requisition form. The Plan denied your request. The Plan says the denial of payment for these services is 
correct, because the documentation submitted does not include a valid physician order, laboratory requisition, 
or medical records for the tests billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific 
lab services is required for covered lab services.  
 
We looked at the file and Medicare rules. The documentation submitted does not include a valid physician 
order or clear intent to order the specific lab services billed on this claim. Based on this information, we 
decided that Medicare rules for coverage of drug tests have not been met. Therefore, we decided that the Plan 
does not have to pay for drug testing provided on November 18, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (CPT 80307 and HCPCS G0482) 
provided to the enrollee on October 31, 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, 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 G0482: 
 
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 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 records 
were provided for review; however, the physician's order was not provider, nor was there any other 
documentation of the enrollee seeing the prescribing physician. 
 
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 G0482) provided to the enrollee on October 31, 
2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the portable oxygen concentrator purchased on June 4, 2019.
You asked the Plan to pay for the portable oxygen concentrator. The Plan denied your request. The Plan says that this is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that purchased oxygen equipment is statutorily non-covered. Therefore, we decided that the Plan does not have to pay for the portable oxygen concentrator purchased on June 4, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PET of the head through thigh (78815). 
 
You asked the Plan to pre-approve the PET. You say that you would like reconsideration because this service is 
medically necessary. The Plan denied your request. The Plan says the requested study would exceed the 
allowed limit of 3 scans for this cancer type. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
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 PET. Our reviewer says that the 
service is not reasonable or medically necessary. Serial PET scans are not indicated for surveillance. Our 
physician reviewer found a PET is not likely to change management over a CT scan. 
 
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 PET have not been met. Therefore, we decided that the Plan does not have 
to pre-approve PET of the head through thigh (78815).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (HCPCS G0483) provided to the enrollee on May 8, 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 medical records do not contain documentation of definitive laboratory results for 22 or more drug classes, including metabolites to support the coding criteria for HCPCS G0483. 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 HCPCS 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 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 it appears that only the first page of the laboratory report has been submitted for review. Therefore, only three classes of drugs are shown to have been tested. As such, the billing of HCPCS G0483 is not supported. 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 (HCPCS G0483) provided to the enrollee on May 8, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services (90832) provided on January 29,
2020.
You asked the Plan to pay for the psychotherapy services. You say that the services were medically necessary.
The Plan denied your request. The Plan says the out-of-network services were not pre-authorized or emergent.
There were network providers available.
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 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 the psychotherapy services (90832) provided on January 29, 2020.