Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the crown. We decided that the Plan does not have to pre-approve 
the core buildup.  
 
You asked the Plan to pre-approve the core buildup and crown. You say that a new full coverage crown and 
build up is recommended for proper restoration. The Plan says that core buildup is not a covered benefit. The 
Plan also says that the x-rays do not show that the enrollee has a cavity under the crown they already have. 
 
We decided that the Plan has to pre-approve the crown.  
 
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 crown 
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 crown. Our reviewer says that the 
crown for tooth #20 meets the Plan's coverage criteria. Our physician reviewer found a replacement crown 
(D2750) for tooth #20 meets the criteria for coverage due to an open margin and recurrent caries. 
 
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 crown have been met. Therefore, we decided that the Plan has to pre-
approve the crown.  
 
We also decided that the Plan does not have to pre-approve the core buildup. 
 
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, core buildup, including any pins when 
required is not among those covered under this benefit. 
 
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 core buildup have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the core buildup. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 10, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
laboratory services provided on March 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on April 13, 2020.
You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.
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 the Guardant360 testing is not supported in the medical record. Specifically, this service should be billed with code 81479. In addition, the appropriate DEX Z code identifier should be entered adjacent in the comment/narrative field. Based on this information, we decided that Medicare rules for coverage of the Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on April 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist telemedicine visit provided a 
participating provider on June 8, 2020. 
 
You asked the Plan to waive the copayment for specialist telemedicine visit. You say that you shouldn't have to 
pay for a phone call. 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 $40 
copayment for physician/practitioner services/specialist.  
 
You have been asked to pay a $40 copayment for specialist telemedicine visit. The correct copayment has been 
applied to the services that were provided. Specialist telemedicine visit falls within the physician/practitioner 
services/specialist 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 specialist 
telemedicine visit provided by a participating provider on June 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided out of network to the enrollee on October 15, 2019.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network 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 has network providers available who can provide the services 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 these services. Therefore, we decided that the Plan does not have to pay for physician services provided out of network to the enrollee on October 15, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on February 3, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
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 definitive drug testing, 22 or more drug classes. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, there is no documentation 
of testing of 22 or more drug classes. Based on this information, we decided that Medicare rules for coverage 
of these services have not been met. 
 
The rules say that testing to confirm that a urine specimen is unadulterated is an internal control process that is 
not separately reportable. 
 
We looked at the file and Medicare rules. The file shows that the tests at issue were urine specimens utilized for 
drug testing. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on February 
3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from October 26, 
2019 to October 29, 2019. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you are appealing with medical 
records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because 
as of October 25, 2019 the enrollee was awaiting transfer to the skilled nursing facility and thus criteria for 
inpatient hospital care were not met. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee was admitted to observation on October 22, 2019. He was found to be 
uremic having missed dialysis the day prior. There were no other acute findings. The treatment plan was to 
return the enrollee to the skilled nursing facility. The record does not show that at the time of inpatient 
admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including 
earlier emergency department and/or observation care) would span at least 2 midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from October 26, 2019 to October 29, 
2019.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the cost share for the office visit for the removal of impacted cerumen 
and a laryngoscopy flexible diagnostic provided on January 8, 2020. 
 
You asked the Plan to waive the cost share for the office visit services, removal of impacted cerumen and a 
laryngoscopy flexible diagnostic. You say that you feel you should not be responsible for this cost share 
amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says 
that the correct cost share has applied per your contract with the Plan 
 
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 does not say in clear and accurate terms 
how much you should expect to pay for an office visit, removal of impacted cerumen and a laryngoscopy.  
 
We looked at your contract with the Plan. We did not see where the contract says enrollees must pay a $198 
deductible or a 20% coinsurance for the services rendered. The Plan contract does not clearly say how much 
enrollees must pay for the services provided. The Plan contract provides a range of what the enrollee could 
possibly be charged with, without an explanation of when and how the different cost share amounts would 
apply. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. 
Therefore, we decided that the Plan has to waive the cost share for the office visit for the removal of impacted 
cerumen and a laryngoscopy flexible diagnostic provided on January 8, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 80061 provided on December 
19, 2019. 
 
You asked the Plan to pay for the laboratory services. 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 80061 is lipid panel. This panel must include the 
following: Cholesterol, serum, total (82465) Lipoprotein, direct measurement, high density cholesterol (HDL 
cholesterol) (83718) Triglycerides (84478). 
 
We find that CPT code 80061 is not supported in the medical record. Specifically, the documentation submitted 
did not include a valid physician order/lab requisition form or medical records (signed by the ordering 
physician) stating exactly what tests were to be performed. In addition, the documentation does not support 
results of the testing of high density cholesterol. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay 
for the laboratory services coded 80061 provided on December 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 29, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed.
We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on January 29, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic procedures provided on January 8, 2020.
You asked the Plan to pay for the therapeutic procedures. The Plan denied your request. The Plan says prior
authorization was not obtained as required under the Plan benefits.
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 therapeutic procedures provided on January 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis and periodic oral evaluation provided on June 3, 2020.
You asked the Plan to pay for the prophylaxis and periodic oral evaluation. You say that you weren't informed you had to change dentists when you signed up. The Plan denied your request. The Plan says out-of-network dental services are not a covered 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, out-of-network dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the prophylaxis and periodic oral evaluation provided on June 3, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for cataract surgery provided by a participating 
provider on February 24, 2020. 
 
You asked the Plan to waive the copayment for cataract surgery. You say that you do not feel like you should 
be responsible for this copayment. 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 $295 
copayment for outpatient surgery.  
 
You have been asked to pay a $295 copayment for cataract surgery. The correct copayment has been applied to 
the surgery that was provided. Cataract surgery falls within the outpatient surgery 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 cataract surgery provided by a participating provider on February 24, 
2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for occupational therapy provided on March 10, 2020. 
 
You asked the Plan to pay for the occupational therapy. The Plan denied your request. The Plan says the Plan 
requires utilization of network providers when possible and available and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented. 
 
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 occupational therapy provided on March 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oxygenator assembly and operation services (CPT 99190) 
provided to the enrollee on April 9, 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 payment for this service is the responsibility of the facility to any vendor. 
 
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 CPT code 99190 is "Assembly and operation of pump with 
oxygenator or heat exchanger (with or without ECG and/or pressure monitoring); each hour." 
 
We find that CPT code 99190 is not supported in the medical record. Specifically, this code is included in the 
payment to the facility. 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 oxygenator assembly and 
operation services (CPT 99190) provided to the enrollee on April 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the presumptive and definitive drug testing (80307 and G0483), along with individual therapeutic drug assays, provided on December 10, 2019.
You asked the Plan to pay for the drug testing. You say that this should be covered. The Plan denied your request. The Plan says the documentation does not include a valid order.
The Plan must follow Medicare rules. Medicare rules say that lab testing may be covered when ordered by a treating provider. The rules also say that the correct codes must be reported for testing. In this case, the order form indicates the intent to perform a Chronic Care Management Profile. It is noted that the full profile is described on the reverse but this is not provided. In addition, for the individual drug assays, these codes represent testing on a serum or plasma sample. The sample in this case is noted to be urine and no plasma/serum was provided. As such, these other codes are not supported. Therefore, we decided that the Plan does not have to pay for the presumptive and definitive drug testing (80307 and G0483), along with individual therapeutic drug assays, provided on December 10, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded G0483, 80177, 80157, 80159, 
80173, 80162 and 80201 provided on December 19, 2019. 
 
You asked the Plan to pay for the laboratory services. 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 G0483, 80177, 80157, 80159, 80173, 80162 and 80201 are not supported in the 
medical record. Specifically, the documentation submitted did not include a valid physician order/lab 
requisition form or medical records signed by the ordering physician stating exactly what tests were to be 
performed. Based on this information, we decided that Medicare rules for coverage of the laboratory services 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 
G0483, 80177, 80157, 80159, 80173, 80162 and 80201 provided on December 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Bevacizumab injection (J9035) received on April 27, 2020.
You asked the Plan to waive the coinsurance for a Bevacizumab injection. You say that this service should be covered fully under the Plan benefit. The Plan denied your request. The Plan says the correct cost-sharing was 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 20% coinsurance for all drugs covered under Medicare Part B. You have been asked to pay $100, or 20% of the Plan-approved amount of $500, for a Bevacizumab injection. A Bevacizumab injection 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 waive the coinsurance for a Bevacizumab injection (J9035) received on April 27, 2020.