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

We decided that the Plan does not have to pay for lab work provided on January 14, 2020 to April 15, 2020 by an out of network (OON) provider.
You asked the Plan to pay for lab work. You say that you have been having this done for a very long time and it has never been an issue before. The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that 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 lab work provided on January 14, 2020 to April 15, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (HCPCS G0481 and CPT 80307) 
provided to the enrollee on January 9, 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 submitted documentation contains an unsigned physician order. 
 
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, 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 
 
HCPCS G0481: 
 
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 
records do not contain a valid physician order or requisition to support the denied codes. The documentation 
contains an unsigned physician order. In addition, there are no authenticated medical records (e.g., a progress 
note) from the ordering provider documenting the treating physician had intended the clinical diagnostic test be 
performed; therefore the billed services cannot be verified. 
 
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 and CPT 80307) provided to the enrollee on January 9, 
2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on May 1, 2020 by an out of 
network (OON) 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 an out-of-network 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 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 May 1, 2020 by 
an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on April 1, 2019 to October 22, 
2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that you want to switch coverage so these services 
would be in-network. 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 physician services provided on April 1, 2019 to 
October 22, 2019 by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency care provided on May 4, 2020. 
 
You asked the Plan to waive the copayment for emergency care. You say that you disagree with the charges 
because your doctor's office was closed due to COVID-19. The Plan denied your request. The Plan says the 
claims were processed correctly and you are being charged the correct 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 $120 
copayment for emergency care.  
 
You have been asked to pay the allowed amount of $108.88, which is less than the $120 copayment for 
emergency care. Emergency care falls 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 care provided on May 4, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse the copayment for outpatient substance abuse services 
provided on March 5, 2020. 
 
You asked the Plan to reimburse the copayment for outpatient substance abuse services. You say that the Plan 
has fully reimbursed you in the past and disagree with the amount they reimbursed. The Plan denied your 
request. The Plan says the claims were processed correctly and you are being charged the correct 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 $40 
copayment for outpatient substance abuse services.  
 
You received outpatient substance abuse services on March 5, 2020. Therefore, you are responsible to pay the 
$40 copayment. Please contact the provider with any questions regarding overpayments or refunds.  
 
You have been asked to pay a $40 copayment for outpatient substance abuse services. Outpatient substance 
abuse services fall within the outpatient substance abuse 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 reimburse the copayment for outpatient substance abuse services provided on March 5, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to 
the enrollee on February 21, 2020. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says this test should be coded with CPT 81479. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have to pay 
for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on February 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam and orthoptic and/or pleoptic training services 
received on November 25, 2019, December 9, 2019, December 16, 2019, and December 30, 2019. 
 
You asked the Plan to pay for the eye exam and orthoptic and/or pleoptic training services. You say that you 
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services 
received are not a covered benefit when provided by an out of network provider. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when they are provided by a network provider. 
 
We looked at the file and the Plan's rules. Review of the file shows that you received these services from an out 
of network provider. Based on this information, we decided that the Plan's rules for coverage of the eye exam 
and orthoptic and/or pleoptic training services have not been met. 
 
Therefore, we decided that the Plan does not have to pay for the eye exam and orthoptic and/or pleoptic 
training services received on November 25, 2019, December 9, 2019, December 16, 2019, and December 30, 
2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (HCPCS G0483) provided to the 
enrollee on July 12, 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 according to the claims data available at the time of the review, the plan was unable to discover 
any evidence of an established relationship between the enrollee and 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 HCPCS code G0483 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; 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 
records do not support an established relationship between the ordering physician and the enrollee. 
 
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 G0483) provided to the enrollee on July 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We are dismissing your case. The Plan agreed to pay for the services. Therefore, there is no need for a
coverage decision.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the retinal diagnostic imaging and the medical eye exam provided on February 10, 2020 and March 9, 2020.
You asked the Plan to waive the copayments for the retinal diagnostic imaging and the medical eye exam. You say that these visits were post-op for a surgery that had taken place last year. You say it was your understanding that there should be no copayments for post-op visits 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 $20 copayment for each in-network Medicare-covered x-ray visit and/or simple diagnostic test and a $20 copayment for visits to an in-network specialist for Medicare-covered exams to diagnose and treat diseases of the eye. You have been asked to pay a $20 copayment for the retinal diagnostic imaging and a $20 copayment for the medical eye exam. The retinal diagnostic imaging falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The medical eye exam falls within the "Vision services" benefit category. Please note, there is no provision in the contract which indicates copayments would be waived if performed as follow-ups to a surgical procedure.
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 copayments for the retinal diagnostic imaging and the medical eye exam provided on February 10, 2020 and March 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on February 13, 2020.
You asked the Plan to waive the copayment for laboratory services. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $15 copayment for laboratory services. You have been asked to pay a $15 copayment for laboratory services. Laboratory services fall 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 laboratory services provided on February 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on March 31, 
2020. 
 
You asked the Plan to waive the copayment for the office visit. You say that the doctor did not do any service 
on your callous. 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 $50 
copayment for each Medicare-covered visit for podiatry services.  
 
You have been asked to pay a $50 copayment for the office visit. The office visit falls within the ?Podiatry 
services? benefit category. The record shows you were billed for the office visit. 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 office visit provided on March 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that these are medically necessary. 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 pre-approve foot orthotics.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve back procedure at T7, T8, T10, T11, T12 thoracic 
kyphoplasty. 
 
You asked the Plan to pre-approve five level kyphoplasty. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that  
 
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 five level kyphoplasty. Our reviewer 
says that the documentation does not support that the requested services are medically reasonable or necessary. 
Our physician reviewer found the enrollee has compression fractures. Five level thoracic kyphoplasty remains 
experimental. Recent literature shows it is not more effective than sham treatment. Therefore, the enrollee does 
not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of five level kyphoplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve back procedure at T7, T8, T10, T11, T12 thoracic kyphoplasty.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Modafinil for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this medication has improved the enrollee's quality 
of life. The Plan denied your request. The Plan says that this is not covered by Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Modafinil for the enrollee.  
 
Benefits for this drug 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMs HF System.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that Medicare may make payment for a Category B IDE
device when part of a Medicare-approved IDE study.
We looked at the file and Medicare rules. The services at issue are a CardioMEMs HF System. This service is a
Category B IDE device. The file shows that the services will not be rendered at a facility enrolled in the
Category B IDE study. Therefore, we decided that the Plan does not have to pre-approve a CardioMEMs HF
System.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need to be able to return to your prior level of 
function. You say that you need the intensive setting for best recovery results. The Plan denied your request. 
The Plan says you can safely receive your care in a less intensive setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the documentation does not indicate that you would be able to fully participate in 
an IRF level of care. Our physician reviewer found that ongoing pain medication and other medication 
management, wound care and daily therapy can be provided at a skilled nursing facility.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.