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

 
We decided that the Plan does not have to pay for a drug test provided on November 11, 2019. 
 
You asked the Plan to pay for the drug test. The Plan denied your request. The Plan says you must receive care 
from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of 
the plan's service area or if the care cannot be provided with an in-network provider, which requires prior 
authorization from the plan. 
 
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 a drug test provided on November 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the specialist office visit and the 
ultrasound provided on January 22, 2020. 
 
You asked the Plan to waive the copayments for the specialist office visit and the ultrasound. You say that your 
claims were not processed correctly. You say the claim denied the ultrasound as a non-participating provider. 
The Plan denied your request. The Plan says the claims were not denied and 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 services obtained from a specialist, or under certain circumstances, treatment by a nurse 
practitioner or physician's assistant or other non-physician health care professionals in a specialist's office and a 
$155 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in 
a physician's office or at a free-standing facility (such as a radiology center or medical clinic).  
 
You have been asked to pay a $20 copayment for the specialist office visit and a $65.42 copayment for the 
ultrasound, which is less than the standard copayment amount. The specialist office visit falls within the 
?Physician/Practitioner Services, Including Doctor?s Office Visits? benefit category. ($20 + $65.42 = $85.42). 
The ultrasound 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 the specialist office visit and the ultrasound provided on 
January 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the full mouth debridement. 
 
You asked the Plan to pre-approve the full mouth debridement. You say that you need your teeth and gums 
cleaned before you develop serious dental problems. You say that this is medically necessary dental care.  The 
Plan denied your request. The Plan says the service is not medically necessary. 
 
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 full mouth 
debridement 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 full mouth debridement. Our 
reviewer says that the criteria for coverage has not been met. Our reviewer says that full mouth debridement is 
only available when an evaluation of the teeth and gums is not possible due to extensive buildup. Our physician 
reviewer found that a full examination and periodontal evaluation were able to be performed on December 30, 
2019, therefore the requested procedure is not medically 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 full mouth debridement have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the full mouth debridement.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from February 7, 2020 
to March 7, 2020. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee 
required no nursing services which would be considered skilled services by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily 
skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
 
 
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 skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from February 7, 2020 to March 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for cardiac rehabilitation services provided by
a participating provider on December 17, 2019.
You asked the Plan to waive the copayment for cardiac rehabilitation services. You say that you do not think
that this copayment is correct. 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 $45
copayment for cardiac rehabilitation services/in-network.
You have been asked to pay a $45 copayment for cardiac rehabilitation services. The correct copayment has
been applied to the services that were provided. Cardiac rehabilitation services fall within the cardiac
rehabilitation services/in-network 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
cardiac rehabilitation services provided by a participating provider on December 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fixed bridge. 
 
You asked the Plan to pre-approve a fixed bridge. You say that the enrollee does not tolerate partials. You say 
that a bridge is an ideal treatment option. The Plan denied your request. The Plan says the records do not 
support a physical or psychological condition(s) that preclude the use of a removable prosthesis 
 
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 a bridge 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 a bridge. Our reviewer says that a fixed 
bridge is not medically necessary. Our physician reviewer found that the records do not show a physical or 
neurological disorder that would preclude the use of a removable partial denture. 
 
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 a bridge have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a fixed bridge.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on January 14, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says 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. 
 
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 
laboratory 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 laboratory services provided on January 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for the testosterone injections and hormone 
implantation procedures provided from December 4, 2019 to April 3, 2020. 
 
You asked the Plan to reduce the cost share for the testosterone injections and the hormone implantation 
procedures. You say that you were not told you would have to pay for the injections. You say you should only 
be responsible for the $15 office visits. 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 20% 
coinsurance for each in-network Medicare-covered Part B drug and a $15 copayment per visit for a specialist 
office visit.  
 
 
You have been asked to pay a total of $365.05 for the testosterone injections and the hormone implantation 
procedures. The testosterone injections fall within the ?Medicare Part B prescription drugs? benefit category. 
The hormone implantation procedures fall the ?Physician/Practitioner services, including doctor?s office visits? 
benefit category. See chart below. 
 
Date of Service Service Allowed Amount Coinsurance/ 
Copayment 
Member 
Liability 
December 4, 2019 Testosterone injection $817.36 20% $163.47 
December 4, 2019 Hormone implantation 
procedure 
$78.16 $15.00 $15.00 
April 3, 2020 Testosterone injection $857.89 20% $171.58 
April 3, 2020 Hormone implantation 
procedure 
$79.07 $15.00 $15.00 
Total    $365.05 
 
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 reduce the cost share for the testosterone injections and hormone implantation 
procedures provided from December 4, 2019 to April 3, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9502) provided on February 12, 
2020 through March 3, 2020. 
 
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says procedure code S9502 has a status code of I 
which is not valid for Medicare purposes. 
 
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 code S9502 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT 
code S9502 has a status indicator of I. This means that CPT code S9502 is not valid for Medicare purposes. 
Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not 
been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9502) 
provided on February 12, 2020 through March 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a cystourethroscopy provided by an in-network provider on January 13, 2020.

You asked the Plan to waive the coinsurance for an outpatient surgery. You say that you don't think you should have to pay for something that you were just going to get removed. The Plan denied your request. The Plan says the correct coinsurance 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 25% coinsurance for outpatient surgery/outpatient hospital. 

You have been asked to pay a 25% coinsurance of the allowed amount for an outpatient surgery. The total allowed amount is $298.90. The total amount you are being asked to pay is $74.73 ($298.90 x 25% = $74.73). An outpatient surgery falls within the outpatient surgery/outpatient hospital 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 coinsurance for a cystourethroscopy provided by an in-network provider on January 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (HCPCS G0480) provided to the enrollee on December 2, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records (signed by the ordering physician) stating exactly what tests are to be performed.
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 G0480 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; 1-7 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 there is no documentation that supports the denied code HCPCS G0480. There is no documentation that contains a valid physician order or requisition.
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 G0480) provided to the enrollee on December 2, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive eye exam (92004) polycarbonate lens (V2784) tint, photochromatic (V2744) provided March 5, 2020.
You asked the Plan to pay for the vision services. You say that you were told this provider was in-network but the claim is processing as out of network and you're receiving a bill. The handbook states that an eye exam is covered in full yet you're being charged. The Plan denied your request. The Plan says the claim was processed and the coinsurance was applied correctly and upgrades are not covered per the plan benefits.
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. The Plan contract says that additional upgrades are not covered. You must pay 50% of the total allowed amount for each out of network exam to diagnose and treat diseases and conditions of the eye.
We looked at the file and the Plan's rules. Upgrades are not covered and you must pay 50% of the total allowed amount for each out of network exam to diagnose and treat diseases and conditions of the eye. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for comprehensive eye exam (92004) polycarbonate lens (V2784) tint, photochromatic (V2744) provided March 5, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (CPT 80307 and HCPCS G0483) 
provided to the enrollee on January 5, 2020. 
 
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 records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 80307: Drug test(s), presumptive, any number of drug classes, qualitative; any number of devices or 
procedures, by instrument chemistry and analyzers (e.g., utilizing immunoassay [EIA, ELISA, EMIT, FPIA, 
IA, KIMS, RIA]), chromatography (e.g., GC, HPLC), and mass spectrometry either with or without 
chromatography, (DAT, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes 
sample validation when performed, per date of service  
 
HCPCS G0483: Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual 
drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited 
to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., 
ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other 
universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and 
variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control 
material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all 
sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if 
performed 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found the 
provided records do not support the denied codes. The records do not contain a valid physician order or 
requisition from the date above to support the denied codes, CPT 80307 and HCPCS G0483. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for drug testing services (CPT 80307 and HCPCS G0483) provided to the enrollee on January 5, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on March 9, 2020. 
 
You asked the Plan to pay for the bitewings. You say that you did not look at the benefit manual prior to your 
appointment because bitewing x-rays had been covered for years. The Plan denied your request. The Plan says 
this service is not a covered benefit. The Plan also says that you did not elect to purchase an optional 
supplemental dental 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 the 
bitewing x-rays (D0274) provided on March 9, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services you received from March 12, 2020, to April 21,
2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider is not
eligible for payment.
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare
program.
We looked at the file and Medicare rules. The provider in question is a licensed profession counselor. This type
of provider is not eligible to enroll in the Medicare program. Payment cannot be made to a provider who is not
enrolled in the Medicare program. 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 services you
received from March 12, 2020, to April 21, 2020.