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

We decided that the Plan does not have to pay for the drug testing services provided on July 10, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the documentation
submitted did not include a valid physician order/lab requisition or medical records.
The Plan must follow Medicare rules. Medicare rules say that 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. The records provided do not contain a valid physician order or lab
requisition stating exactly which testing was to be performed. 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 the drug testing services provided on July 10, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveProlia 60mg/ml syringe.You asked the Plan to pre-approveProlia 60mg/ml syringe. You say that the requested medication is 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. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Prolia 60mg/ml syringe. Our reviewer says that the medication is not medically necessary. Our physician reviewer found based on the records provided, the documentation does not support that the second refill of the Prolia on July 9, 2020 is medically reasonable and necessary or safe and effective for you as it is too soon to refill.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia 60mg/ml syringe have not been met.Therefore, we decided that the Plan does not have to pre-approveProlia 60mg/ml syringe.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on December 19, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the documentation
submitted did not include a physician order/lab requisition or medical records stating exactly what tests are to
be performed.
The Plan must follow Medicare rules. Medicare rules say that 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. The records provided do not contain a valid physician order or lab
requisition stating exactly which testing was to be performed. 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 the drug testing services provided on December 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown on tooth #7 provided on December 31, 2019.
You asked the Plan to pay for the crown. You say that in-network providers are subject to 30% reimbursement for one crown per year. The Plan denied your request. The Plan says the x-rays show that you have an implant in the place of tooth #7. The Plan also says that implant-related services are not covered under Medicare or your 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. The contract clearly states that charges for any type of implant and all related services are excluded from coverage. Therefore, we decided that the Plan does not have to pay for the crown on tooth #7 provided on December 31, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 and G0482 provided on June 6, 2019.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes 80307 and G0482 are not supported in the medical record. Specifically, the documentation does not support evidence of an established relationship between the enrollee and the ordering physician. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded 80307 and G0482 provided on June 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the medical eye exam provided on
November 26, 2019.
You asked the Plan to waive the copayment for the medical eye exam. You say that you were under the
impression that diabetics do not pay for eye exams. The Plan denied your request. The Plan says you have been
charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20
copayment for a medical eye exam.
You have been asked to pay a $20 copayment for the medical eye exam. The medical eye exam falls within the
"Vision care" benefit category. The medical record shows a diagnosis of vitreous degeneration which makes
the eye exam medical in nature.
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 provided on November 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special pump services rendered on February 15, 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 services are not separately payable.
The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are statutorily excluded. The provider submitted a claim for procedure code 99190 (special pump services). This code has a status indicator of X and no separate Medicare payment. Payment is included in the payment to the facility. Therefore, we decided that the Plan does not have to pay for the special pump services rendered on February 15, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 18, 2019 by a
non-participating provider.
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 services were rendered by a non-participating provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The referring provider is not a
network provider with the Plan. The Plan has network providers available who can provide the items/services
at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that
would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay
for the medical services provided on November 18, 2019 by a non-participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the dialysis treatments provided from January 1, 2020 to January 31, 2020. You asked the Plan to waive the cost share for the dialysis treatments. You say that the provider is in-network and you would like the claims reprocessed to the in-network rate and to apply towards your maximum out-of-pocket total for in-network claims. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $975 deductible that applies towards out-of-network dialysis treatments and 20% coinsurance for out-of-network services for kidney dialysis. The dialysis treatments you asked the Plan to waive the cost share for falls within the "Services to treat kidney disease" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $975 deductible that applies towards out-of-network dialysis treatments and 20% for out-of-network services for kidney dialysis. The record shows that the provider is out-of-network and this total amount applies to your combined maximum out-of-pocket amount. 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 cost share for the dialysis treatments provided from January 1, 2020 to January 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for Unspecified maxillofacial prosthesis (D5999) provided
November 19, 2019.
You asked the Plan to pay for the prosthesis. You say that you had a sleep study which revealed you have sleep
apnea. You could have chosen 3 options and chose a mandibular advancement device. The Plan denied your
request. The Plan says the request for coverage is for an unlisted code. The appropriate code for the provided
service is E0486.
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 the request for coverage is for an unlisted code (D5999). The appropriate code for the provided
service is E0486. The health plan will approve E0486 if it is requested. Based on this information, we decided
that Medicare rules for coverage of the prosthesis have not been met. Therefore, we decided that the Plan does
not have to pay for Unspecified maxillofacial prosthesis (D5999) provided November 19, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other medication management, wound/skin care, and daily therapy can be provided at a SNF. In this case, the enrollee is mostly minimal assist for functional transfers and activities of daily living (ADL's) and a less intensive, longer duration of therapy will allow for measurable gains to be attained within a reasonable, and predicted period. An IRF intensity is not warranted. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for2D oral/facial photographic image (D0350) provided January 21, 2020.You asked the Plan to pay forthe dental services. You say that you followed the guidelines given in the Evidence of Coverage and found the provider on the Plans online site. You confirmed first that they accepted the plan. You should not be held accountable.The Plan denied your request. The Plan says this service is not covered under the plan benefits.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 for2D oral/facial photographic image (D0350) provided January 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forspecialist visits provided from January 23, 2020 to February 24, 2020.You asked the Plan to waive the copayments forspecialist visits. You say that you should only owe a $45 copayment per each visit.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 $75 copayment for services obtained by an out-of-network specialist.You had an out-of-network specialist visit on January 23, 2020. Therefore, you are responsible to pay the $75 copayment. You had an out-of-network specialist visit on February 4, 2020. Therefore, you are responsible to pay the allowed amount of $45.74, which is less than the $75 copayment.  You had an out-of-network specialist visit on February 24, 2020. Therefore, you are responsible to pay the allowed amount of $45.74, which is less than the $75 copayment.  The total amount you owe is: $166.48. You have been asked to pay the total copayment amount of $166.48 for specialist visits. Specialistvisits fall within the physician/practitioner services, including doctor's office visits 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 forspecialist visits provided from January 23, 2020 to February 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered on November 27, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.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 test at issue in this appeal was 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 forthe laboratory services rendered on November 27, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for drug testing services (CPT 80307 and HCPCS G0483) provided to the
enrollee on May 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 that the submitted documentation did not contain sufficient detail to support the billed charges.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of the denied codes is:
CPT 80307:
Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument
chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]),
chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART,
DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when
performed, per date of service.
HCPCS G0483:
Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and
distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to,
GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays
(e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope
or other universally recognized internal standards in all samples (e.g., to control for matrix effects,
interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched
quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or
quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including
metabolite(s) if performed
We asked our coding 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 reviewers says that the
services at issue in this case were supported by the medical records. Our coding reviewer found the
documentation includes a claim form with a place of service of 11. There is no other documentation found that
contradicts this place of service.
We looked at this coder'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 pay for
drug testing services (CPT 80307 and HCPCS G0483) provided to the enrollee on May 18, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay foran outpatient visit (99212) provided on February 13, 2020.You asked the Plan to pay forthe outpatient visit. You say that you would like reconsideration because this service was billed correctly.The Plan denied your request. The Plan says the claim was submitted with an incorrect code for the particular place of treatment.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 99212is office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self-limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or family. We find that CPT code 99212 is not supported in the record. Specifically, this is an outpatient code that has been billed with Place of Service code 23 for Emergency Department. Per AMA CPT Manual Guidelines for 99212, this E/M code is used to report E/M services provided in the office or in an outpatient or other ambulatory facility. This is not an appropriate code to bill for services provided in an emergency department.  Based on this information, we decided that Medicare rules for coverage of the outpatient visit have not been met.Therefore, we decided that the Plan does not have to pay foran outpatient visit (99212) provided on February 13, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay foran EGD provided on September 11, 2019 by an out of network (OON) provider.You asked the Plan to pay foran EGD. You say that you were told that prior authorization was not required.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that they have no record of previous phone calls.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 foran EGD provided on September 11, 2019 by an out of network (OON) provider.