Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for foot orthotics purchased on March 10, 2020.
You asked the Plan to reimburse you for foot orthotics. You say that you have worn the custom inserts for years and need new ones. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to reimburse you for foot orthotics purchased on March 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (CPT 80307 and HCPCS G0483)
provided to the enrollee on August 26, 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 the documentation submitted did not include a valid physician order/lab requisition or medical
records (signed by 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 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.
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 the
submitted medical records do not contain any evidence supporting an established physician-patient
relationship. There is no clinical information indicating rationale for testing or indicating that the results of
testing were used to manage the enrollee's medical care.
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 G0483) provided to the enrollee on August 26,
2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider for diagnostic testing.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says the requested provider is non-contracting and out-of-network.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network provider for diagnostic testing.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventative immunization provided on January 17,
2020.
You asked the Plan to pay for the Tetanus vaccination. You say that the Plan should pay this claim. The Plan
denied your request. The Plan says based on clinical records this vaccination was administered for routine
immunization.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Tetanus
vaccination. The Plan follows the same rules.
Records do not show that you have been injured or directly exposed to any illness related to the Tetanus
vaccination. Therefore, we decided that the Plan does not have to pay for the preventative immunization
provided on January 17, 2020.
Benefits for the Tetanus vaccination may be available under Medicare Part D. Contact the Plan that administers
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (HCPCS G0481) provided to the
enrollee on April 24, 2019.
You asked the Plan to pay for the services. You say that this should be paid for, as it was denied in error. The
Plan denied your request. The Plan says the documentation received does not include definitive laboratory
results for 8-14 drug classes to support the coding criteria.
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 supported by the medical records. Our physician reviewer found the
submitted medical records do not contain any indication that the results of testing were used to manage the
enrollee's care.
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 (HCPCS G0481) provided to the enrollee on April 24, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the solid tumor genomic assay provided on February 24,
2020.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says comprehensive
genomic profile testing is limited to one test per specimen.
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 testing provided is not supported in the medical records. In this case, there were insufficient
records provided to show the results of this testing would be used to determine a specific diagnosis or specific
treatment strategy for disease or illness present in the enrollee at the time of service. This testing is not covered
for screening purposes. 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 solid tumor genomic assay provided on
February 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extractions teeth 6, 7, 8, 9, 10, 11, 14, 17, 24, 25, 26, 27, 31 (D7210x13) provided February 19, 2020.
You asked the Plan to pay for the surgical extractions. You say that your condition was not normal but critical and does not fall under the same guidelines as normal tooth extraction. Please reconsider this issue. The Plan denied your request. The Plan says this request exceeds the benefit limitation.
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 contract allows coverage for 2 extractions. The plan has approved coverage for surgical extractions for teeth 3 and 4. Therefore the benefit has been exhausted. 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 surgical extractions teeth 6, 7, 8, 9, 10, 11, 14, 17, 24, 25, 26, 27, 31 (D7210x13) provided February 19, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (CPT 80307 and HCPCS G0483) provided to the enrollee on June 4, 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 the documentation submitted did not include a valid physician order/lab requisition or medical records (signed by 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 (e.g., utilizing immunoassay [e.g., EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (e.g., GC, HPLC), and mass spectrometry either with or without chromatography, (e.g., 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 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.
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 the submitted medical records do not contain any evidence supporting an established physician-patient relationship. There is no clinical information indicating rationale for testing or indicating that the results of testing were used to manage the enrollee's medical care. 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 G0483) provided to the enrollee on June 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical supplies to be provided by an out of network provider.
You asked the Plan to pre-approve the bra and forms. You say that you want to continue to get your supplies from the out of network provider. The Plan denied your request. The Plan says there are in network providers available.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the medical supplies to be provided by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued in home visits and services to be provided by
an out of network (OON) provider.
You asked the Plan to pre-approve these OON services. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the requested services can be provided by a network
provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
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. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
continued in home visits and services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate (E1390) provided on January 27, 2020 by an out-of-network provider.
You asked the Plan to waive the coinsurance for the DME. You say that this service should be paid for by the Plan because you were told this would be covered in full. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received an oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate (E1390) provided on January 27, 2020 by an out-of-network provider. You have been asked to pay 20% coinsurance of the allowed amount for durable medical equipment. The allowed amount is $75.20. The total you owe is $15.04 ($75.20 x 20% = $15.04). Your EOC states, enrollees must pay 20% coinsurance for DME and related supplies. 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 oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate (E1390) provided on January 27, 2020 by an out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on January 30, 2020.
You asked the Plan to waive the copayment for the ambulance transport. The Plan denied your request. The Plan says that the cost share was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for each one-way Medicare covered ground ambulance trip. You have been asked to pay a $247.22 copayment for the ambulance transport. The ambulance transport falls within the one-way Medicare covered ground ambulance trip benefit category. This means that you have been asked to pay less than the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance transport provided on January 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical nutrition therapy.
You asked the Plan to pre-approve medical nutrition therapy services. The Plan denied your request. The Plan
says the enrollee does not meet the criteria for coverage.
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services
only for enrollees with renal disease or diabetes.
The records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the
Plan does not have to pre-approve medical nutrition therapy.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on January 17, 2020.
You asked the Plan to pay for the services provided. You say that the testing allows the enrollee to avoid
another biopsy following disease progression. The Plan denied your request. The Plan says coverage is limited
to one test per specimen, and precludes the use of any other molecular testing on the specimen.
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 looked at the file and the rules. Medicare rules show that a Guardant360 test is billed using CPT code
81479 with 1 unite of service. 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 Guardant360 testing provided on
January 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the specialist office visit provided on May 18, 2020.
You asked the Plan to reduce the copayment for the specialist office visit. You say that you should not be responsible for the full copayment amount. 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 $35 copayment for each specialist visit. You have been asked to pay a $35 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 reduce the copayment for the specialist office visit provided on May 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a raised toilet seat purchased on March 20, 2020.
You asked the Plan to reimburse you for a raised toilet seat. You say that because of an injury your doctor
wrote you a prescription for a toilet riser. The Plan denied your request. The Plan says this item is not a covered
benefit.
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered
because they are not primarily medical in nature.
While a raised toilet seat may be appropriate in this case, neither the Plan nor Medicare offers coverage of this
item. Therefore, we decided that the Plan does not have to reimburse you for a raised toilet seat purchased on
March 20, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation provided on February 26, 2020 by an OON provider.
You asked the Plan to pay for the psychiatric diagnostic evaluation. The Plan denied your request. The Plan says this service was rendered by a non-plan provider. The Plan also says that there is no prior authorization on file.
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 the psychiatric diagnostic evaluation provided on February 26, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Zoster (shingles) vaccine provided on March 18, 2020.
You asked the Plan to pay for the provided vaccine. You say that the treatment was the second in a series of two injections. The Plan denied your request. The Plan says the service is a Part D prescription drug.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the provided vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the provided vaccine. The drug is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the Zoster (shingles) vaccine provided on March 18, 2020.
Benefits for the provided vaccine may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.