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

 
We decided that the Plan does not have to pay for the crown (D2740) and core buildup (D2950) provided on 
February 28, 2020. 
 
You asked the Plan to pay for the crown (D2740) and core buildup (D2950). You say that you trusted insurance 
to be ethical, effective, responsible and considerate. You say that you should be taken care of. 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 crown 
(D2740) and core buildup (D2950) provided on February 28, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the 20% coinsurance charged for Remicade on April 17, 2020.
You asked the Plan to waive or reduce this coinsurance. You stated in your appeal to the Plan and also in a letter mailed directly to this office, that in 2019 the Plan representative told you the cost of this drug should be what you were paying then. You stated that you were paying about $20 at that time. You stated you would not have signed up if you knew it was this expensive. The Plan denied your request. The Plan says this cost share was charged based on the Medicare allowed amount for this drug and your Plan contract agreement.
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 drugs. Remicade is a Medicare Part B drug. 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 or reduce the 20% coinsurance charged for Remicade on April 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the special alveoloplasty procedure provided on 
March 4, 2020. 
 
You asked the Plan to reimburse you for the special alveoloplasty procedure. You say that the Plan should 
reimburse you for the dental claim. The Plan denied your request. The Plan says the special alveoloplasty 
procedure does not meet the requirements for approval. 
 
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 reimburse you for 
the special alveoloplasty procedure provided on March 4, 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 29, 
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 denied codes are not supported. 
 
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 81057: 
 
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 29, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an office visit provided by a participating 
provider on January 21, 2020. 
 
You asked the Plan to waive the deductible for an office visit. You say that you went to an in-network provider. 
You say that you do not agree you owe this much. The Plan denied your request. The Plan says the correct 
deductible has been applied. 
 
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 $150 deductible for annual deductible/in-network.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category annual 
deductible/in-network. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a 
$150 deductible for annual deductible/in-network. This cost sharing is a contractual obligation that had not 
been met at the time an office visit was received on January 21, 2020. The total amount you are being asked to 
pay is $111.76. Therefore, we decided that the Plan does not have to waive the deductible for an office visit 
provided by a participating provider on January 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays (D0274) and fluoride varnish application 
(D1206) provided on March 9, 2020.  
 
You asked the Plan to pay for the bitewing x-rays (D0274) and fluoride varnish application (D1206). You say 
that the dentist requires these x-rays annually. You say that you wonder why insurance would cover 
unnecessary services versus the one recommended by the dentist. 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) and fluoride varnish application (D1206) provided on March 9, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided January 12, 2020 to January 
15, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that inpatient care was medically 
necessary. The Plan denied your request. The Plan says that coverage criteria was 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 supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the review has determined that the record showed that at the time of inpatient admission the 
admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency 
and/or observation care) would span two 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 been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided January 12, 2020 to January 15, 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 laboratory services (80201, 80162, 80159 and 80173) 
provided December 3, 2019. 
 
You asked the Plan to pay for laboratory services. You say that you would like reconsideration based on the 
medical records provided. The Plan denied your request. The Plan says the documentation submitted did not 
support that this testing was performed with blood sampling. 
 
The Plan must follow Medicare rules. The rules say that the provider, supplier, or beneficiary, as appropriate, 
must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the 
amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of laboratory services have not been met. Specifically, the records show that a urine sample was taken 
for services that require a blood sample. Therefore, we decided that the Plan does not have to pay for laboratory 
services (80201, 80162, 80159 and 80173) provided December 3, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the screening mammogram and screening digital breast tomosynthesis rendered on September 18, 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 the claim is a duplicate.
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the Plan on a separate claim for the same date of service. 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 screening mammogram and screening digital breast tomosynthesis rendered on September 18, 2019.
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 
March 2, 2020. 
 
You asked the Plan to pay for the prophylaxis and periodic oral evaluation. You say that you have used the 
dentist for the last two years with no denials. You say that you should have been notified if he is now 
considered a privately contracted provider. The Plan denied your request. The Plan says payment cannot be 
issued for services performed by a provider who has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
the prophylaxis and periodic oral evaluation provided on March 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for telehealth services provided by an out-of-
network provider on April 21, 2020. 
 
You asked the Plan to waive the coinsurance for telehealth services. You say that you did not want to take up 
your doctor's time so you used this service online. You say that you thought this provider was in-network. The 
Plan denied your request. The Plan says the correct coinsurance has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for physician/practitioner services/out-of-network/provider services.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for telehealth services. The total 
allowed amount is $10.99. The total amount you are being asked to pay is $2.20 ($10.99 x 20% = $2.20). The 
correct coinsurance has been applied. Telehealth services fall within the physician/practitioner services/out-of-
network/provider 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 coinsurance for telehealth 
services provided by on April 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on May 19, 2020 by an out of 
network provider. 
 
You asked the Plan to pay for the medical services. You say that the physician is listed as participating. The 
Plan denied your request. The Plan says the physician is not participating in your 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 has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. In the provider list the Provider Details do not list your plan under this physician. 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 medical services provided on May 19, 2020 by an out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient care provided from 6:29 PM on November 1, 2019 
to November 4, 2019. 
 
You asked the Plan to pay for inpatient care. You say that the patient needed acute care. The Plan denied your 
request. The Plan says the enrollee was stable for transfer. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 inpatient care. Our reviewer says that the 
criteria for coverage of these services have not been met. Our physician reviewer found the review indicates 
that as of 6:29 p.m. on November 1, 2019, the enrollee was stable for transfer to the nearest facility via 
ambulance transfer. By this time, the treating physician had deemed the member clinically stable for transfer. 
The enrollee had been evaluated by both Neurology and Nephrology and both specialists had noted that the 
enrollee's metabolic encephalopathy was due to a combination of opiate use, acute renal failure and the 
infectious process of pneumonia. By this time, the enrollee had been treated with IV antibiotics and IV fluids, 
and lab test results and diagnostic imaging had ruled out an acute pulmonary event.  
The review has determined that all inpatient care provided after 6:29 p.m. on November 1, 2019 at the out-of-
network facility was not needed on an emergent basis. The review has determined that the treating physician 
did not document that the patient was not stable for transfer on any dates of service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care have not been met. Therefore, we decided that the Plan does not 
have to pay for inpatient care provided from 6:29 PM on November 1, 2019 to November 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on September 17, 2019 to 
November 6, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for home health services. You say that these services were requested by the 
member's family. You say that you would like this claim reprocessed and approved for payment. The Plan 
denied your request. The Plan says prior authorization was not 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 has network providers 
available who can provide the items/services at issue in this appeal. 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 home health services provided on September 17, 
2019 to November 6, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the presumptive and definitive drug testing provided on 
January 6, 2020. 
 
You asked the Plan to pay for the drug testing. You say that this is medically necessary testing. The Plan 
denied your request. The Plan says the claims history does not support that there is an established relationship 
between the ordering provider and the enrollee. Without evidence of this, payment cannot be made. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the presumptive and 
definitive drug testing provided on January 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation provided on March 18, 2020.
You asked the Plan to pay for the psychiatric diagnostic evaluation. The Plan denied your request. The Plan says you must receive your care from a network provider. In most cases, care you receive from an out-of-network provider will not be covered. If you need medical care that Medicare requires our Plan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-network provider. You, or your PCP, must obtain authorization from the Plan prior to seeking care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for a psychiatric diagnostic evaluation provided on March 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on January 28, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed services 
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. 
 
The documentation shows the enrollee received presumptive and definitive drug testing. We looked at the file 
and the rules. Medicare rules say that providers must produce medical records showing why the lab services 
provided were medically necessary. There were insufficient records to show that the test was individualized to 
identify specific non-prescribed medications or illicit substances. The records provided do not document 
concerns based on clinical review and judgement. 
 
We find that CPT codes 80157, 80159, 80162, 80173, 80177, and 80201 are not supported in the medical 
record. The testing at issue is performed on a blood sample. The documentation provided did not show a blood 
sample was obtained from the enrollee for the date of service at issue.  Based on this information, we decided 
that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan 
does not have to pay for the lab services provided on January 28, 2020.