Persius/hicric huggingface dataset:
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency room visits on February 29, 2020 to March 11, 2020.
You asked the Plan to waive the copayment for the emergency room visits. You say that the copayments should be waived and the services should be billed as office visits. The Plan denied your request. The Plan says the correct copayments were 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 $90 copayment for Emergency Care. You have been asked to pay a $90 copayment for each emergency room visit. The emergency room visits fall within the Emergency 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 emergency room visits on February 29, 2020 to March 11, 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 July 22, 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 physician order/lab requisition or medical records
stating exactly what tests are to be performed.
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,
nDESI, 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
provided documentation does not include a specific order form or progress notes to help show which tests were
ordered or whether definitive testing was required or ordered.
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 July 22,
2019.
Appeal type: Imaging
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 July 22, 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 physician order/lab requisition or medical records stating exactly what tests are to be performed.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, nDESI, 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 provided documentation does not include a specific order form or progress notes to help show which tests were ordered or whether definitive testing was required or ordered.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 July 22, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 17, 2020 by an
out of network (OON) provider.
You asked the Plan to pay for psychotherapy visit. You say that your provider depends on the facility to obtain
proper authorization. The Plan denied your request. The Plan says the denial of payment for this service is
correct, because this provider is out-of-network with the Plan and 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 the medical services provided on February 17,
2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does nothave to pre-approvea dental consultation (D9310) and dental extraction, tooth 16 (D7210) to be provided by an oral surgeon.You asked the Plan to pre-approvethe dental services. You say that you are currently in pain and the pain radiates though your mouth and down your throat.The Plan denied your request. The Plan says the requested service is not covered under the plan 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. The health plan contract specifically says services must be performed by a participating general dentists.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 pre-approvea dental consultation (D9310) and dental extraction, tooth 16 (D7210) to be provided by an oral surgeon.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forthe Guardant360 test provided to the enrollee on February 12, 2020.You asked the Planto pay forthe test. You say that this should be paid for.The Plandenied your request. The PlansaysMedicare requires use of CPT 81479 to report a Guardant360? molecular pathology genomic profiling for NSCLC.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 various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare rules for coverage of the test have not been met.Therefore, we decided that the Plandoes not haveto pay forthe Guardant360 test provided to the enrollee on February 12, 2020
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approveOrthovisc injections.You asked the Plan to pre-approveOrthoviscinjections. You say that the requested Orthovisc injections are medically necessary. The Plan denied your request. The Plan says that the requested Orthovisc injections are not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Orthovisc injections. Our reviewer says that the requested Orthovisc injections are medically necessary. Our physician reviewer found this enrollee presents with recurrent severe right knee pain with associated swelling and clicking. Functional limitations are noted in ambulatory ability. Clinical exam findings have been consistent with imaging evidence of bone-on-bone right knee lateral compartment osteoarthritis. She has failed to improve with conservative treatment, including activity modification, medications, cortisone injection and bracing. She underwent prior Orthovisc injections over the past 6 years with long-term pain reduction to minimal symptoms and improvement in activities of daily living. Under consideration is a request for a series of Orthovisc injections. Evidence based medical peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee, and indicated that repeat injections are effective in delaying time to total knee replacement for patients with knee osteoarthritis which failed conservative treatment. Current evidence based medical guidelines state that medical evidence suggests intra-articular hyaluronic acid injections may relieve osteoarthritic knee pain in some patients. Repeat Orthovisc injections are reasonably indicated for treatment of this enrollee's knee pain given the failure of comprehensive conservative treatment, worsening pain and functional limitations, and significant previous benefit with these injections. Therefore, the documentation would support that the Orthovisc injections are medically reasonable and necessary and safe and effective for treatment of this enrollee's severe right knee osteoarthritis.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Orthovisc injections have been met.Therefore, we decided that the Plan has to pre-approveOrthovisc injections.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 provided on February 10, 2020.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says that you must receive your care from a network provider. In most cases, care you receive from an out-of-network provider (a provider who is not part of our plan's network) 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 laboratory services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for laboratory services provided on February 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 heavy duty power wheelchair.
You asked the Plan to pre-approve a Group 2 heavy duty power wheelchair (K0807). You say that you feel safe and functional with a motorized scooter. The Plan denied your request. The Plan says Medicare does not cover power mobility devices for community mobility and this type of scooter is not covered.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file shows that your home cannot accommodate a scooter. The requested Group 2 heavy duty power wheelchair (K0807) is not covered by Medicare. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 2 heavy duty power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, prophylaxis, and bitewings provided on January 23, 2020.
You asked the Plan to pay for the periodic oral evaluation, prophylaxis, and bitewings. You say that you understand the terms of your dental Plan to mean that a reimbursement is to be made for the partial cost of any services, including services rendered by an out-of-network provider. The Plan denied your request. The Plan says this treating provider has opted out of Medicare, effective November 25, 2016. The Plan also says that the Plan is unable to make payment for services provided by a dentist that 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 periodic oral evaluation, prophylaxis, and bitewings provided on January 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray, additional intraoral periapical x-ray, and panoramic x-ray provided on March 4, 2020.
You asked the Plan to pay for the first intraoral periapical x-ray, additional intraoral periapical x-ray, and panoramic x-ray. You say that you thought you were entitled to 2 cleanings per year. You also say that you thought the x-rays were part of the cleaning. 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, 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 first intraoral periapical x-ray, additional intraoral periapical x-ray, and panoramic x-ray provided on March 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on June 19, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. 
 
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on June 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Zoster (shingles) vaccine (90750) and administration
(90471)
You asked the Plan to pre-approve a shingles vaccine and administration. You say that this should be covered
because you previously paid for a shingles vaccine. The Plan denied your request. The Plan says this vaccine is
only covered by Medicare Part D.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a shingles vaccine
and administration. The Plan follows the same rules.
Records do not show that you have been injured or directly exposed to any illness related to a shingles vaccine
and administration. Therefore, we decided that the Plan does not have to pre-approve a Zoster (shingles)
vaccine (90750) and administration (90471)
Benefits for a shingles vaccine and administration 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 the laboratory services provided on March 16, 2020 by a
non-contracted provider.
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 were rendered by a non-contracted 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 requested provider in this case is not a network provider with the Plan. The referring provider 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 laboratory services provided on March 16, 2020 by a non-contracted provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hot or cold packs therapy (97010) and the mechanical traction therapy (97012) provided on January 2, 2020. 
 
You asked the Plan to pay 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 these services are not a covered benefit under your contractual policy. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the hot or cold packs therapy (97010) and the mechanical traction therapy (97012) provided on January 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for digital analysis of electroencephalogram (95957) provided on January 29, 2020 through January 30, 2020.
You asked the Plan to pay for the digital analysis of electroencephalogram. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service 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 code 95957 is digital analysis of electroencephalogram (EEG)(eg, for epileptic spike analysis). We asked our coder 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 digital analysis of electroencephalogram. Our reviewer says that CPT code 95957 does not meet criteria for billing or reimbursement consideration. Our reviewer found the documentation did not include a digital analysis of electroencephalogram for the billed dates of service. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the digital analysis of electroencephalogram have not been met. Therefore, we decided that the Plan does not have to pay for digital analysis of electroencephalogram (95957) provided on January 29, 2020 through January 30, 2020.