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

 
We decided that the Plan does not have to pay for the core buildup on tooth #19 provided on March 2, 2020. 
 
You asked the Plan to pay for the core buildup. The Plan denied your request. The Plan says that this is not 
covered under 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. The Plan covers one 
crown/buildup per tooth every five years. 
 
We looked at the file and Medicare rules. The file indicates the Plan covered a crown on tooth #19 on the same 
date of service. Based on this information, we decided that the Plan's rules for coverage of the core buildup 
have not been met. Therefore, we decided that the Plan does not have to pay for the core buildup on tooth #19 
provided on March 2, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the treatment of a bladder lesion (51720) 
provided on March 17, 2020 and March 25, 2020. 
 
You asked the Plan to waive the copayments for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayments 
have been applied correctly to the services provided. 
 
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 
copayment for each in-network specialist?s office visit for chemotherapy.  
 
You have been asked to pay a $50 copayment ($25 x 2 treatments) for the specialist office visits provided for 
chemotherapy. 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 treatment of a bladder lesion (51720) 
provided on March 17, 2020 and March 25, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on January 27, 
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 80157: 
 
Carbamepazine; free 
 
CPT 80159: 
 
Clozapine 
 
CPT 80162: 
 
Digoxin; total 
 
CPT 80173: 
 
Haloperidol 
 
CPT 80177: 
 
Levetiracetam 
 
CPT 80201: 
 
Topiramate 
 
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 
 
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 
 
 
We find that the denied codes are not supported in the medical record. Specifically, there is no valid physician 
order for these services, and the services were done by urine sampling rather than blood sampling. 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 provided to the enrollee on January 27, 
2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded G0483 provided on January 20, 2020. 
 
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 G0483 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation 
submitted did not support that drug tests, 22 or more drug classes was performed. Laboratory tests were not 
submitted from the billing provider. 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 G0483 provided on January 20, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded 80307 provided on February 3, 2020. 
 
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 80307 is 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. 
 
We find that CPT code 80307 is not supported in the medical record. Specifically, the documentation submitted 
did not include a physician order/lab requisition form or medical records stating exactly what tests were to be 
performed. The submitted laboratory requisition form indicates that a CQP minus THC panel was requested. 
The submitted documentation does not itemize what tests are included in this panel. 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 provided on February 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the coinsurance for Leuprolide acetate received on June 18, 
2020. 
 
You asked the Plan to adjust the coinsurance for Leuprolide acetate (J9217). You say that this coinsurance is 
more than the Plan quoted you. The Plan denied your request. The Plan says you were charged the coinsurance 
correctly for the number of units given. 
 
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 Medicare Part B prescription drugs.  
 
You have been asked to pay 20% coinsurance for Leuprolide acetate (J9217). Leuprolide acetate (J9217) falls 
within the Medicare Part B prescription drugs 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 adjust the coinsurance 
for Leuprolide acetate received on June 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transcatheter tricuspid valve repair (0569T, 0570T) provided 
on February 13, 2020. 
 
You asked the Plan to pay for transcatheter tricuspid valve repair. You say that two surgeons are supported in 
the records. The Plan denied your request. The Plan says co-surgeons are not payable on these procedures. 
 
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that 
CMS designates to be ?inpatient-only? services. These services have an OPPS status indicator of ?C? in the 
OPPS Addendum B and are listed together in Addendum E of each year?s OPPS/ASC final rule.  
 
The service at issue in this appeal was billed with CPT codes 0569T and 0570T. These codes are listed with a 
status indicator of ?C? on Addendum B of the 2020 OPPS/ASC final rule. This means these services have been 
designated as ?inpatient only?, and therefore must be billed as part of an inpatient admission. Therefore, we 
decided that the Plan does not have to pay for transcatheter tricuspid valve repair (0569T, 0570T) provided on 
February 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) rendered by the 
out of network (OON) provider on January 21, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the subsequent nursing facility care (99309) rendered by the out of network (OON) provider on 
January 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the copayment from $50 to $30 for the nail debridement 
(11721) and the office visit (99204) provided on March 31, 2020. 
 
You asked the Plan to adjust the copayment for these services. You say that you are requesting a 
reconsideration of the Plan's denial. The Plan denied your request. The Plan says the copayment has been 
applied correctly to the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for each Medicare-covered podiatry visit.  
 
You have been asked to pay a $50 copayment for the Medicare-covered podiatry visit provided. 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 adjust the copayment from $50 to $30 for the nail debridement (11721) and the office visit 
(99204) provided on March 31, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) testing provided on 
February 3, 2020. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the claim is not 
billed correctly according to Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that the services at issue have not been billed with the appropriate revenue code or type of bill code. 
The documentation does not show that a valid claim was submitted to the plan. Based on this information, we 
decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have 
to pay for the magnetic resonance imaging (MRI) testing provided on February 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient mental health stay provided 
from January 27, 2020 to February 25, 2020. 
 
You asked the Plan to waive the copayment for an inpatient mental health stay. You say that the facility was 
inappropriate for many reasons and feel that you should not owe the charges due to lack of treatment. 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 $250 
copayment per day for days 1-7 for inpatient mental health care.  
 
You had an inpatient mental health stay from January 27, 2020 to February 25, 2020. Therefore, you are 
responsible to pay a $250 copayment for days 1-7 (January 27, 2020 to February 2, 2020). $250 (copayment) x 
7 (inpatient days) = $1,750.00. 
 
You have been asked to pay the total copayment amount of $1,7500 for an inpatient mental health stay. An 
inpatient mental health stay falls within the inpatient mental health care 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 an inpatient mental health stay provided from January 27, 2020 to 
February 25, 2020.  
 
We note your complaints about the facility. Your complaint is a grievance that must be answered by the health 
plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on July 22, 2019. 
 
You asked the Plan to pay for the chiropractic services. You say that you were informed that this provider was 
participating with the Plan and you believe he should be paid. The Plan denied your request. The Plan says no 
authorization was obtained. 
 
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 chiropractic services provided on July 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for DME and related supplies provided from 
February 14, 2020 to February 26, 2020. 
 
You asked the Plan to waive the deductible for DME and related supplies. You say that you disagree with the 
charges because the device is necessary and you got a prescription for it. 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. Your 
contract with the Plan says that there is a $1,000 deductible for out-of-network DME and related supplies.  
 
You received DME and related supplies from February 14, 2020 to February 26, 2020 from an out-of-network 
provider. Therefore, you are responsible to pay your share of the out-of-network cost-sharing charges. The 
record shows that you had paid $0 toward the $1,000 deductible. Therefore, you are responsible to pay the total 
allowed amount of $269.08. 
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category DME and 
related supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a 
$1,000 deductible for out-of-network services DME and related supplies. This cost sharing is a contractual 
obligation that had not been met at the time DME and related supplies were received on February 14, 2020 to 
February 26, 2020. Therefore, we decided that the Plan does not have to waive the deductible for DME and 
related supplies provided from February 14, 2020 to February 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a back brace (L0650) provided on March 9, 2020. 
 
You asked the Plan to pay for a back brace. You say that this is supported by the records. The Plan denied your 
request. The Plan says the records do not contain an order or proof of delivery. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order or proof of delivery which support medical necessity for 
the supplies provided in this case. An order and proof of delivery were not included in the submitted 
documents. The record shows that the Plan made several attempts to obtain the necessary documentation 
without success. Therefore, we decided that the Plan does not have to pay for a back brace (L0650) provided on 
March 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a second intraoral x-ray (D0230), endodontic therapy 
(D3320), and a consultation (D9310) provided on August 2, 2019. 
 
You asked the Plan to pay for a second intraoral x-ray, endodontic therapy, and a consultation. You say that 
you were told these services would be covered. The Plan denied your request. The Plan says these services are 
not covered. 
 
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, it covers only one intraoral x-ray per 
year and the other services at issue are not among those covered under this benefit. Therefore, we decided that 
the Plan does not have to pay for a second intraoral x-ray (D0230), endodontic therapy (D3320), and a 
consultation (D9310) provided on August 2, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a SNF stay provided from April 20, 2020 to 
April 30, 2020. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that this SNF stay should be considered a 
new admission because it was for a separate injury. 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 $0 
copayment each day for days 1-20 and a $160 copayment for days 21-50, per benefit category, for SNF care.  
 
You had a SNF stay from April 20, 2020 to April 30, 2020. The record shows that you had a previous SNF stay 
within the same benefit category from February 24, 2020 to March 13, 2020 for a total of 19 days. You are not 
being charged for day 20. You are responsible to pay a $160 copayment for days 21-30 (April 21, 2020 to April 
30, 2020). $160 (copayment) x 10 (SNF days) = $1,600.00. 
 
You have been asked to pay the total copayment amount of $1,600.00 for a SNF stay. A SNF stay falls within 
the SNF care 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 a SNF stay provided from 
April 20, 2020 to April 30, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services. 
 
You asked the Plan to pay for the ambulance services. You say that on the date of service you were 
experiencing shortness of breath and you were gasping for air. Your daughter called for help and she was 
instructed to call 911 by a nursing service. You stated that when the emergency responders arrived, they 
checked your vitals and your blood pressure was extremely high. You say that as they were explaining your 
options, you began to feel better and your blood pressure started going down. You stated that you were afraid 
that if you went to the hospital, you would be isolated due to Covid-19 and so you signed the release form. You 
asked the Plan to reconsider providing coverage for the services because your medical bills would have been 
much higher if you were transported. The Plan denied your request. The Plan says these services are not a 
covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 23, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services.