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

We decided that the Plan does not have to waive the copayment forthe specialist office visit provided on April 7, 2020.You asked the Plan to waive the copayment forthe specialist office visit. You say that you were told there would be no copayment and you would like the copayment waived. 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 $40 copayment per specialist visit. You have been asked to pay a $40 copayment for the specialist office visit. The specialist office visit falls 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 copayment forthe specialist office visit provided on April 7, 2020. Your complaint about the COVID-19 period is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered bythe Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a voice and resonance analysis (92524) provided on February 20, 2020.
You asked the Plan to waive the copayment for a voice and resonance analysis. You say that you never received this service. The Plan denied your request. The Plan says this service processed correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for speech and language pathology services. You have been asked to pay a $40 copayment for a voice and resonance analysis. A voice and resonance analysis falls within the speech and language pathology services benefit category. The medical records support that this service took place. 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 a voice and resonance analysis (92524) provided on February 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a percutaneous nerve stimulator.
You asked the Plan to pre-approve a percutaneous nerve stimulator. You say that this is a wearable device for
auricular neurostimulation therapy. The Plan denied your request. The Plan says these devices are not covered
by Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the file and Medicare rules. This type of device is non-covered by Medicare. The FDA approval
for this device was approved as substantially equivalent to the NSS-2 Bridge device therefore it is also
noncovered. Based on this information, we decided that Medicare rules for coverage of a percutaneous nerve
stimulator not been met. Therefore, we decided that the Plan does not have to pre-approve the requested
percutaneous nerve stimulator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays (D0274), intraoral-periapical x-rays
(D0220 & D0230) and periodontal evaluation (D0180) provided on January 31, 2020.
You asked the Plan to pay for the bitewing x-rays (D0274), intraoral-periapical x-rays (D0220 & D0230) and
periodontal evaluation (D0180). You say that you were informed everything was preventive and covered. The
Plan denied your request. The Plan says the services are not covered 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 for the
bitewing x-rays (D0274), intraoral-periapical x-rays (D0220 & D0230) and periodontal evaluation (D0180)
provided on January 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup, including any pins when required and
endodontic therapy provided on April 6, 2020.
You asked the Plan to pay for the core buildup and endodontic therapy. You say that you had emergency oral
surgery. You also say that you are living on social security with no other income. The Plan denied your request.
The Plan says dental services are not covered under your medical plan. The Plan also says that you do not
currently have dental coverage.
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid
for by Medicare. Therefore, we decided that the Plan does not have to pay for the core buildup, including any
pins when required and endodontic therapy provided on April 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on March 4, 2020.
You asked the Plan to pay for laboratory services. The Plan denied your request. The Plan says the enrollee
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
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 March 4, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to providehome health services.You asked the Plan to providehome health services. You say that you want someone to come to your home to give you injections so you do not have to go to the specialist's office.The Plan denied your request. The Plan says there is no physician order or plan of care for home health, or certification of homebound status.ThePlan must follow Medicare rules. The rules say that an enrollee must be homebound for home health care services to be covered. The file does not show that you are homebound.Therefore, we decided that the Plan does not have to providehome health services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to payfordrug testing services (HCPCS G0481) provided to the enrollee on August 28, 2019.You asked the Plan to pay forthe 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); therefore the billed code cannot be verified.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 G0481 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; 8-14 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 coded correctly. Our physician reviewer found the review has determined that the records do not support the coding of G0481. There is no valid order/requisition in the records to support the code.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 fordrug testing services (HCPCS G0481) provided to the enrollee on August 28, 2019
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for molecular genetic hereditary predictive screening testing provided to
the enrollee on December 18, 2019.
You asked the Plan to pay for the testing. You say that this is medically necessary. The Plan denied your
request. The Plan says that Medicare says screening services with no relation to a medical diagnosis of disease
for the health of the patient are not a benefit.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is medically necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for the testing. Our reviewer says that the
requested services are considered medically reasonable and necessary in this case. Our physician reviewer
found the tests ordered included testosterone, free T3, progesterone, cortisol, estradiol, FSH, LH, DHEA-S,
SHBG, and Estrone. Based on the provided diagnoses and included test results the above tests appear to be
justified. There was a positive ANA warranting follow-up ESR and the patient had diagnosed vitamin D
deficiency which warrants testing for this. Also, the enrollee was diagnosed with menopausal symptoms which
warrants all the above hormone testing.
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 testing have been met. Therefore, we decided that the Plan has to pay for
molecular genetic hereditary predictive screening testing provided to the enrollee on December 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on August 5, 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 there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay for the drug testing rendered on August 5, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Gastrointestinal (GI) Effect Comprehensive Stool Profile testing provided on October 14, 2019. You asked the Plan to pay for laboratory tests. You say that even though this testing may not be the standard of care, you still feel that it was medically necessary. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these tests are experimental/investigational and not medically necessary. 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 laboratory tests. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support clinical findings including signs, symptoms, or medical conditions which would benefit from the results of this testing. There was no other justification provided to consider this case an exception. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of laboratory tests have not been met. Therefore, we decided that the Plan does not have to pay for Gastrointestinal (GI) Effect Comprehensive Stool Profile testing provided on October 14, 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 December 9, 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, 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 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 there
were no claims submitted for an evaluation and management service. Review of claims history for this
member, and a review of the submitted documentation did not contain evidence of a relationship with the
ordering physician as required per CMS guidelines. The review has determined that the records do not support
the denied codes.
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 December 9,
2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forinitial observation care (99220) provided on November 12, 2019.You asked the Plan to pay forinitial observation care. You say that authorization was requested and approved for this admission.The Plan denied your request. The Plan says initial care was already billed and paid.The Plan must follow Medicare rules. Medicare rules say that payment for an initial observation care code is for all the care rendered by the ordering physician on the date the patient's observation services began. All other physicians who furnish consultations or additional evaluations or services while the patient is receiving hospital outpatient observation services must bill the appropriate outpatient service codes.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of initial observation care have not been met. Specifically, the record shows that another provider billed for Initial Observation Care on November 11, 2019 for the same admission. Billing of another Initial Observation Care code is not allowed in this circumstance.Therefore, we decided that the Plan does not have to pay forinitial observation care (99220) provided on November 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda.
You asked the Plan to pre-approve Keytruda. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says payment for this request should be submitted to your Medicare Administrative Contractor (MAC).
The Plan must follow Medicare rules. Medicare rules say that routine costs associated with clinical trials are the responsibility of Original Medicare. We looked at the file and Medicare rules. Review of the file shows that the enrollee is enrolled in a clinical trial. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound care provided by a participating
hospital on February 5, 2020 to February 25, 2020.
You asked the Plan to waive the copayment for wound care. You say that this was in a hospital but in a wound
care office. 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 $200
copayment for outpatient surgery/outpatient hospital facility visit.
You have been asked to pay less than a $200 for wound care. The total amount you are being asked to pay is
$642.80 which is less than your copayment amount of $1,000 ($200 x 5 visits = $1,000). Wound care falls
within the outpatient surgery/outpatient hospital facility visit 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 wound care provided by a participating hospital on February 5, 2020 to February
25, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on July 17, 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 support the lab services 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 July 17, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 and G0483 provided on June
18, 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 G0483 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
G0483 provided on June 18, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.You asked the Plan to pre-approvethe SNF services. You say that the records provided support the need for SNF care.The Plan denied your request. The Plan says enrollee does not meet the medical necessity criteria for coverage of SNF care.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 pre-approve the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had stable vital signs, and was treated with uncomplicated dressings for BLE stasis dermatitis and a venous ulcer of the LLE. Our physician reviewer found that the enrollee received physical therapy, occupational therapy, and speech therapy in the SNF. By the dates in question, the enrollee was at a contact guard to minimal assist level with functional mobility, including gait to 100 feet with a rolling walker. The enrollee required varying assist with activities of daily living. The enrollee tolerated a regular diet and thin liquids. There are no identifiable skilled therapy service needs. There are no identifiable skilled nursing service needs.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 SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services