Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper denture (D5213).
You asked the Plan to pre-approve the dental item. You say that partial dentures are a covered benefit. You also say that the benefits for Ohio have not been updated. The Plan denied your request. The Plan says partial denture is not listed as a covered service.
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 partial upper denture is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a partial upper denture (D5213).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the insulin injection, per 5 units.You asked the Plan to pay for the insulin. You say that you have diabetes, but take medication daily instead of insulin. You also say that the insulin was given to you by hospital staff before your surgery.The Plan denied your request. The Plan says insulin is considered a self-administered drug. The Plan says insulin is not covered under your Part B Medicare plan.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pay for the insulin injection, per 5 units.Benefits for the insulin may be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the PET scan provided on October 25, 2019.
You asked the Plan to reduce the copayment for the PET scan. You say that you should be charged for a x-ray copayment. 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 $135 copayment for each Medicare-covered MRI, PET scan, Nuclear Medicine visit. You have been asked to pay a $135 copayment for the PET scan. The PET 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 reduce the copayment for the PET scan provided on October 25, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible forphysical therapy provided from October 15, 2019 through October 28, 2019.You asked the Plan to waive the deductible forphysical therapy. You say that you were given the wrong information prior to beginning treatment. You say that the physical therapy should be covered under your regular deductible.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 combined in and out-of-network deductible is $500, which applies to all items and services except those specifically excluded by the Plan's contract. This is the amount you have to pay out-of-pocket before the plan will pay its share for your Medicare Part A and Part B covered services. Out-of-network outpatient rehabilitation is not excluded from the deductible.The item or service you asked the Plan to waive the deductible for falls within the "Outpatient rehabilitation services" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your combined in and out-of-network,$500 deductible applies to out-of-network outpatient rehabilitation. This cost sharing is a contractual obligation thathad not been met at the time physical therapy was received from October 15, 2019 to October 28, 2019.Therefore, we decided that the Plan does not have to waive the deductible forphysical therapy provided from October 15, 2019 through October 28, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an occlusal guard (D9944).
You asked the Plan to pre-approve the occlusal guard. You say that you asked a plan representative if your provider had submitted an authorization for the occlusal guard and root canal. The Plan denied your request. The Plan says occlusal guard is not listed as a covered dental item.
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 occlusal guard is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an occlusal guard (D9944).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0482 provided on November 4, 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.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 did not include a valid physician order/lab requisition or medical records stating exactly what tests were to be performed. 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 forthe drug testing coded G0482 provided on November 4, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy (HIT) services provided from October 30, 2019 to November 6, 2019 billed with code S9328.
You asked the Plan to pay for the HIT services. You say that you have been given inconsistent reasons why this code is not payable and feel it should be paid since it is listed as valid on the CMS website. The Plan denied your request. The Plan says this code is not payable by Medicare.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. CPT code S9328 has a status indicator of "I", meaning that it is invalid for Medicare billing purposes. Based on this information, we decided that Medicare rules for coverage of the HIT services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy (HIT) services provided from October 30, 2019 to November 6, 2019 billed with code S9328.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on November
20, 2019.
You asked the Plan to waive the copayment for laboratory services. You say that the blood work was for your
annual physical. You say that you have never been charged for labs before. The Plan denied your request. The
Plan says the copayment applied 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 $20 for
Medicare-covered laboratory tests.
You have been asked to pay a $20 copayment for the laboratory services. The laboratory services fall within
the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. Outpatient diagnostic
tests are considered a separate service. 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 laboratory
services provided on November 20, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forgenetic screening testing provided on August 23, 2019.You asked the Plan to pay forscreening test. You say that you are appealing with records to support the codes billed.The Plan denied your request. The Plan says the denial of payment for these services is correct, because the enrollee's treating provider did not order these tests and the enrollee did not have any signs or symptoms to indicate that these tests were medically necessary and being used to manage or treat a specific medical problem or diagnosis.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.There is no documentation in the record of a concern for a specific issue for which the enrollee's treating provider ordered this testing. This was provided in the absence of signs or symptoms of a medical condition, which means it is screening in nature. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay forgenetic screening testing provided on August 23, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ankle/foot orthosis provided to the enrollee on July 10, 2019.You asked the Plan to pay for the orthosis. You say that this was medically necessary for the enrollee.The Plan denied your request. The Plan says that documentation indicates services are not necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay for the ankle/foot orthosis provided to the enrollee on July 10, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial observation care and advanced care planning
provided on February 20, 2019.
You asked the Plan to pay for the initial observation care and advanced care planning. You say that these
services were performed in good faith. 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 enrollee'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 initial observation care and advanced care planning
provided on February 20, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 30 additional routine transportation trips (A0120).
You asked the Plan to pre-approve 30 additional routine transportation trips. You say that the additional transportation trips are necessary for you to be able to go to your appointments. The Plan denied your request. The Plan says the benefit has been exhausted. Therefore, coverage criteria has not been met.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 30 one-way transportation trips per calendar year and 22 trips to and from plan approved locations. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve 30 additional routine transportation trips (A0120).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveInsulin Lisp Inj 100/ml.You asked the Plan to pre-approveInsulin Lisp Inj 100/ml. You say that the medication is necessary.The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveInsulin Lisp Inj 100/ml.Benefits for Insulin Lisp Inj 100/mlmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forthe train of four testing (CPT 95999) provided on September 10, 2019.You asked the Plan to pay forCPT 95999. The Plan denied your request. The Plan says this is a bundled serviceThe 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 95999 is "Unlisted neurological or neuromuscular diagnostic procedure".We find that CPT code 95999 is not supported in the medical record.Specifically, train of four testing is not an unlisted procedure. There is a more appropriate CPT code for train of four testing. Additionally, train of four testing is a bundled procedure and is not separately payable. Based on this information, we decided that Medicare rules for coverage of CPT 95999 have not been met.Therefore, we decided that the Plan does not have to pay forthe train of four testing (CPT 95999) provided on September 10, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on
November 13, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that you believed there would
be no charge because the ambulance was ordered by your provider. The Plan denied your request. The Plan
says that you were charged correclty.
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 $265
copayment per date of service for ground ambulance services regardless of the number of trips.
You have been asked to pay a $265 copayment for the ambulance transport. The ambulance transport falls
within the per date of service for ground ambulance services benefit category. This means that you have been
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have
to waive the copayment for the ambulance transport provided on November 13, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay foran additional unit of radiation dosimetry calculation (77300) and an additional unit of treatment devices (77334) provided on October 9, 2019 through October 31, 2019.You asked the Plan to pay forthe additional units. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the units billed exceed the per day amount per Medicare.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 additional units. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical records did not support the medically necessity of more than 10 units for each of these services. 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 additional units have not been met.Therefore, we decided that the Plan does not have to pay foran additional unit of radiation dosimetry calculation (77300) and an additional unit of treatment devices (77334) provided on October 9, 2019 through October 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a  injection.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says the role of this injection for osteoarthritis is uncertain.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 pre-approve the injection. Our reviewer says that the requested injection is not considered medically reasonable and necessary in this case. Our physician reviewer found the current medical literature and national guidelines do not support this medication as a treatment for knee inflammation. The American Association of Orthopedic Surgery guidelines as well as the MCG Health guidelines consider this treatment not medically necessary. In this case, the available documentation does not support that patient has had extensive non-operative (conservative) treatment to address her knee pain. This would involve therapy, activity modification, weightless, and steroid injections. Given the documentation
provided for review, the enrollee does not have the indications for this injection. 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe full mouth debridement (D4355) provided on November 26, 2019.You asked the Plan to reimburse you forthe dental service. You say that you went to the dentist office for a cleaning. You say that if they were going to perform a service other than what he was there for, they should have advised him that it would not be covered. You say that you should be reimbursed for the service because you went in for a routine cleaning.The Plan denied your request. The Plan says full mouth debridement is not listed as a covered service.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 full mouth debridement is not among those covered under this benefit.Therefore, we decided that the Plan does not have to reimburse you forthe full mouth debridement (D4355) provided on November 26, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit provided on January 7, 2020 by an OON provider.
You asked the Plan to pay for the outpatient office visit. You say that you asked the enrollee's primary physician for a referral to this provider. You say that a second opinion was necessary. The Plan denied your request. The Plan says this visit was not authorized by the Plan. The Plan also says the enrollee self-referred to this provider.
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 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 outpatient office visit provided on January 7, 2020 by an OON provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the nuclear stress test provided on
December 4, 2019.
You asked the Plan to reduce the copayment for the nuclear stress test. You say that the nuclear stress test was
done at your cardiologist's office and not a hospital. 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 $250
copayment for nuclear medicine at an outpatient hospital setting.
You have been asked to pay a $250 copayment for the nuclear stress test. The nuclear stress test falls within the
"Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows the
service was provided at an outpatient hospital.
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 copayment for the nuclear stress test provided on December 4, 2019.