Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to apply in-network cost sharing for the urology services provided on September
3, 2019.
You asked the Plan to apply in-network cost sharing for the urology services. You say that this should be
processed as in-network because this provider's office is in-network with the Plan. The Plan denied your
request. The Plan says that it was confirmed that this PA is not in-network with the Plan.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract
provider are considered approved by the plan unless notice is provided that the services will not be covered.
The Plan follows these rules.
You were provided with these services by a PA. This PA works in the same office as an MD. PA services are
only covered under the general supervision of an MD. You provided a billing statement clearly showing that
the services of the MD on a different date were covered as in-network. The Plan did not provide evidence that
the supervising MD was out of network for this date of service. Under Medicare rules, this means the PA visit
is considered approved by the Plan. Therefore, we decided that the Plan has to apply in-network cost sharing
for the urology services provided on September 3, 2019.
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 drug testing provided on December 19, 2019.
You asked the Plan to pay for drug tests. You say that you have been unable to find any discrepancies between
the codes billed and the supporting medical documentation. The Plan denied your request. The Plan says the
denial of payment for these services is correct, because the documentation submitted does not include a valid
physician order, lab requisition, or medical records stating exactly which tests were to be performed.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific
lab services is required for covered lab services.
We looked at the file and Medicare rules. The documentation submitted does not include a valid physician
order or clear intent to order the specific lab services billed on this claim. Based on this information, we
decided that Medicare rules for coverage of drug tests have not been met. Therefore, we decided that the Plan
does not have to pay for drug testing provided on December 19, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on January 17, 2020.
You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says all
non-emergent services received with a non-Plan provider require approval by the Plan prior to the services
being rendered.
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services,
plans are not required to make payments for any services received by enrollees that are not provided directly by
the Plan or through arrangements made by the Plan.
The services at issue in this appeal were not provided in an emergency or urgent care situation. These services
were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not
have to pay for nurse practitioner services provided on January 17, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on February 27, 2020. 
 
You asked the Plan to pay for the services provided. You say that the enrollee was not on hospice. The Plan 
denied your request. The Plan says the provider needs to bill Original Medicare for the services rendered. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the medical services provided on February 27, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copay for the outpatient surgery services provided on 
March 10, 2020. 
 
You asked the Plan to waive the copay for the surgery services. You say that you were not told that you would 
have a $200 copay. The Plan denied your request.  
 
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 $200 
copay for outpatient surgery.  
 
You have been asked to pay a $200 copay for the surgery services. The services fall 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 copay for the outpatient surgery services 
provided on March 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pontic (D6240) and two retainer crowns (D6750 x2) 
provided on March 13, 2020. 
 
You asked the Plan to pay for the pontic and retainer crowns. You say that these are very common dental 
procedures and should be covered. You also say that these services were necessary for your overall health. The 
Plan denied your request. The Plan says these services are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
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 pontic 
(D6240) and two retainer crowns (D6750 x2) provided on March 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for enteral formula (B4034, B4152, B4155) provided July 3, 
2019 to August 6, 2019. 
 
You asked the Plan to pay for enteral formula. You say that this was medically necessary. The Plan denied your 
request. The Plan says there is no proof of delivery in the file. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery. There is no proof of delivery or medical record in the  
file for the dates of service at issue. The record shows that the Plan made several attempts to obtain the 
necessary documentation without success. Therefore, we decided that the Plan does not have to pay for enteral 
formula (B4034, B4152, B4155) provided July 3, 2019 to August 6, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the echocardiogram provided on March 12,
2020.
You asked the Plan to waive the copayment for the echocardiogram. You say that you should not be paying
more than the insurance for the ultrasound. 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 $125
copayment for each in-network Medicare-covered radiological diagnostic services, not including x-rays,
performed in a physician's office or at a free-standing facility (such as a radiology center or medical clinic).
You have been asked to pay a $125 copayment for the echocardiogram. The echocardiogram falls within the
"Outpatient Diagnostic Tests and Therapeutic Services and Supplies" 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 the echocardiogram provided on March 12, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services (99337) provided on January 16, 2020
by an out of network (OON) provider.
You asked the Plan to pay for the physician services. You say that the service was medically necessary. The
Plan denied your request. The Plan says the services were not emergent or pre-authorized. There were 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 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 the physician services (99337) provided on January 16, 2020 by an out of
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve neurology services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve neurology services. You say that you have seen this doctor since 2014. You say that you would like approval for these services. The Plan denied your request. The Plan says there are in-network providers who can provide these services.
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 neurology services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment charged for urgent care services provided on 
March 31, 2020. 
 
You asked the Plan to waive this copayment. You say that the staff at urgent care did not really help your 
condition. The Plan denied your request. The Plan says this copayment was charged based on the Plan contract 
agreement for this type of service. 
 
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 $35 
copayment for urgent care services. 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 charged for urgent care services 
provided on March 31, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (CPT 80307) provided to the enrollee on March 23, 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 Current Procedural Terminology (CPT) code 80307 (1 Unit) remains 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 code 80307 is "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 CPT code 80307 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a 
place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). 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) provided to the enrollee on March 23, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiation therapy services provided on February 13, 2020. 
 
You asked the Plan to pay for the radiation therapy services. The Plan denied your request. The Plan says that 
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 radiation therapy services provided on February 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on March 4, 2019 by an out-of-
network provider. 
 
You asked the Plan to pay for the dental services. You say that you are appealing your cost-share responsibility 
for the services you received. The Plan denied your request. The Plan says you do not have out-of-network 
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. 
 
Review of the file show that you received dental services on March 4, 2019 by an out-of-network provider. 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 dental services provided on March 4, 2019 by 
an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Testosterone pellet provided on 
September 18, 2019. 
 
You asked the Plan to waive the coinsurance for this drug. You say that you cannot afford this. The Plan denied 
your request. The Plan says that you are financially liable for the cost sharing 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 each Medicare-covered Part B drug.  
 
You have been asked to pay a 20% coinsurance for this drug. This drug falls within the Medicare-covered Part 
B drug 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 the Testosterone pellet provided 
on September 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for special periapical dental x-rays (D0220 and D0230) provided 
on March 12, 2020 by an in-network provider. 
 
You asked the Plan to pay for the dental services. You say that the representative did not inform you that the x-
rays are not a covered benefit. The Plan denied your request. The Plan says the service is not a covered benefit 
under the plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
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. This service is not listed in your EOC as a covered benefit; therefore, it 
is not covered. Therefore, we decided that the Plan does not have to pay for special periapical dental x-rays 
(D0220 and D0230) provided on March 12, 2020 by an in-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on February 4, 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 Healthcare Common Procedure Coding System (HCPCS) code G0483, and Current Procedural Terminology (CPT) code 80307, 80157, 80177, 80201, 80162, 80159 and 80173 remain 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: 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. CPT 80157: Carbamazepine; free. CPT 80177: Levetiracetam. CPT 80201: Topiramate. CPT 80162: Digoxin; total. CPT 80159: Clozapine. CPT 80173: Haloperidol. 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 records do not support the correct coding of the denied codes. The records did not contain a valid physician order or requisition to support the above codes. 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 provided to the enrollee on February 4, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the esophagogastroduodenoscopy billed for services 
provided on November 27, 2019. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the billed code 
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. 
 
In this case, the CPT Code Manual definition of code 43235 is esophagogastroduodenoscopy, flexible, 
transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate 
procedure). 
 
We find that CPT code 43235 is not supported in the medical record provided. The documentation does not 
show that the services at issue were performed on this date 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 esophagogastroduodenoscopy billed for services provided on November 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on March 9, 
2020. 
 
You asked the Plan to pay for this claim. 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 to the enrollee on March 9, 2020.