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

We decided that the Plan does not have to pay more for the problem focused limited oral evaluation (D0140), prefabricated post and core in addition to crown (D2954), and endodontic therapy (D3330) provided on November 4, 2020, and November 30, 2020 by an OON provider.

You asked the Plan to pay more for the problem focused limited oral evaluation, prefabricated post and core, and endodontic therapy. You say that you believe these services should be covered at 50%. The Plan denied your request. The Plan says the total amount of $1,216.50 was applied correctly as member liability. The Plan also says that cost sharing is a contractual obligation under the Plan and cannot be waived.

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, you are responsible for 50% of the allowed amounts for the prefabricated post and core and endodontic therapy, plus the difference between the billed amount and allowed amount. Therefore, we decided that the Plan does not have to pay more for the problem focused limited oral evaluation (D0140), prefabricated post and core in addition to crown (D2954), and endodontic therapy (D3330) provided on November 4, 2020, and November 30, 2020 by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0482 provided on July 8, 2020.

You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.

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 G0482 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; 15-21 drug class(es), including metabolite(s) if performed.

We find that CPT code G0482 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0482 provided on July 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing services provided on July 7, 2020.

You asked the Plan to pay for the testing services. You say that you have no knowledge of the enrollee's coverage prior to the specimen's arrival at the lab. 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 code.

We looked at the file and the rules. In this case, the records do not show that the enrollee's specimen was obtained at an independent lab. 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 definitive drug testing services provided on July 7, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan provided on December 23, 2020.

You asked the Plan to waive the copayment for the CT scan. You say that the provider is trying to take advantage of patients by attempting to charge more than they should for basic services. The Plan denied your request. The Plan says you have been asked to pay 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 $250 copayment for Medicare-covered diagnostic radiology services ($100 ultrasound). For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the standard $250 copayment for the CT scan.

You have been asked to pay a $213.58 copayment for the CT scan. The CT scan 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 CT scan provided on December 23, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for an ultrasound provided by a participating provider on June 11, 2020.

You asked the Plan to waive the co-payment for an ultrasound. You say that you do not agree with this co-payment. The Plan denied your request. The Plan says the correct co-payment has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $160 co-payment for outpatient diagnostic test/radiological diagnostic services.

You have been asked to pay $112.79 which is less than your co-payment amount of $160 for an ultrasound. an ultrasound falls within the outpatient diagnostic test/radiological diagnostic services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the co-payment for an ultrasound provided by a participating provider on June 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the blood smear services coded 85060 provided on December 22, 2020.

You asked the Plan to pay for the blood smear services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as 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 85060 is blood smear, peripheral, interpretation by physician with written report.

We find that CPT code 85060 is not supported in the medical record. Specifically, this code has a Professional component/Technical component indicator of 8. As per Medicare guidance, Professional component/Technical component indicator 8 are Physician interpretation codes, this indicator identifies the professional component of clinical laboratory codes for which separate payment may be made only if the physician interprets an abnormal smear for hospital inpatient. No payment is recognized for code 85060 furnished to hospital outpatients or non-hospital enrollees. Based on this information, we decided that Medicare rules for coverage of the blood smear services have not been met. Therefore, we decided that the Plan does not have to pay for the blood smear services coded 85060 provided on December 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a cone beam (D0367), resin-based fillings (D2332) and intraoral x-rays (D0220, D0230) provided on August 28, 2020 and November 11, 2020.

You asked the Plan to pay for the dental services. You say that you cannot afford these charges because you live on a limited income. The Plan denied your request. The Plan says the cone beam is not listed as a covered service under your dental benefit. In addition, the other services cannot be covered as you have met and exceeded your annual maximum allowance of $2,500.

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 cone beam is not among those covered under this benefit, and your annual maximum allowance of $2,500 has been met. Therefore, we decided that the Plan does not have to pay for a cone beam (D0367), resin-based fillings (D2332) and intraoral x-rays (D0220, D0230) provided on August 28, 2020 and November 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for scaling in the presence of gingival inflammation (D4346) provided on September 9, 2020.

You asked the Plan to pay for the scaling procedure. You say that you know you are entitled to a cleaning every year and feel this service should be covered under that benefit. The Plan denied your request. The Plan says this service is not covered by the Plan's supplemental dental benefit.

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. The Plan does offer dental cleanings; however, these are specific services that are billed with unique codes. The service you had is not the same as these cleaning types. Therefore, we decided that the Plan does not have to pay for scaling in the presence of gingival inflammation (D4346) provided on September 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on May 20, 2020.

You asked the Plan to pay for the services provided. You say that you have no knowledge of enrollee coverage prior to the specimen's arrival at the lab. The Plan denied your request. The Plan says the place of service must reflect the location of the enrollee when the specimen was obtained.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.

We looked at the file and the rules. In this case, the records do not indicate the enrollee's sample was taken at an independent lab. 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 lab services provided on May 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on September 18, 2020 by an out of network (OON) provider.

You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that the referring provider is also 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 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 had network providers available who could have provided 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 September 18, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pulp vitality tests (D0460) provided on January 7, 2021.

You asked the Plan to pay for the pulp vitality tests. You say that you would like this service to be covered.The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan. The Plan also says that you did not purchase an additional dental rider.

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 pulp vitality tests (D0460) provided on January 7, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapy services provided from November 24, 2020 to November 30, 2020.

You asked the Plan to pay for the therapy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.

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 therapy services are not supported in the medical record. Specifically, the claim was not submitted with the required modifier to process and pay the claim. The claim was billed with 420 rev code without a physical therapy procedure code and appropriate modifier. Based on this information, we decided that Medicare rules for coverage of the therapy services have not been met. Therefore, we decided that the Plan does not have to pay for the therapy services provided from November 24, 2020 to November 30, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Azathioprine for the enrollee.

You asked the Plan to pre-approve this drug. You say that the enrollee has done well on this medication. The Plan denied your request. The Plan says that this is a self-administered drug that is covered under Part D.

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 Azathioprine 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the BLS routine disposable supplies (A0382) provided November 13, 2020.

You asked the Plan to pay for the disposable supplies. You say that the enrollee was removed from hospice care 11/07/20 for medical services that have been denied. Returned to hospice care 11/14/20. You have letter of approval for services dates 11/09/20.The Plan denied your request. The Plan says Medicare does not make separate payment for ambulance supplies.

The Plan must follow Medicare rules. Medicare rules say that oxygen and other items and services provided as part of the transport are included in the fee schedule base payment rate and are not separately payable. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the disposable supplies have not been met.Therefore, we decided that the Plan does not have to pay for the BLS routine disposable supplies (A0382) provided November 13, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided on August 20, 2020.

You asked the Plan to pay for the physical therapy. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the physical therapy. 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 physical therapy provided on August 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 provided on October 2, 2020.

You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.

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 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 find that CPT code G0483 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0483 provided on October 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for lab work provided by a participating provider on February 1, 2021.

You asked the Plan to waive the co-payment for lab work. You say that this was part of your annual wellness exam. The Plan denied your request. The Plan says the correct co-payment has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 co-payment for outpatient diagnostic tests/laboratory tests.

You have been asked to pay a $10 co-payment for lab work. When additional services are provided during an annual wellness exam, additional co-payments are applied. Lab work is considered additional services; therefore, the correct co-payment has been applied. Lab work falls within the outpatient diagnostic tests/laboratory tests 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 co-payment for lab work provided by a participating provider on February 1, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on August 13, 2020.

You asked the Plan to pay for the physical therapy services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the physical therapy 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 physical therapy services provided on August 13, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for physical therapy provided from
September 11, 2020, through December 23, 2020.

You asked the Plan to waive the co-payment for the physical therapy. The Plan denied your request. The Plan says you must pay $15 for each Medicare-covered physical therapy visit.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 co-payment for outpatient rehabilitation services.

You have been asked to pay a $15 co-payment for the physical therapy. The physical therapy falls within the outpatient rehabilitation services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the co-payment for physical therapy provided from September 11, 2020, through December 23, 2020.