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

We decided that the Planhasto pay fordrug testing services (CPT 80307 and HCPCS G0482) provided to the enrollee on November 20, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthatthe records do not support the services billed.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriateCPT 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 (maps to 80301, 80302, 80303, 80304 and G0479HCPCS G0482: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 asked our physician reviewer to carefully review the case fileand apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewers says that the services at issue in this case were supported by the medical records. Our physician reviewer found a signed copy of the requisition (order) was subsequently resubmitted. This would establish the relationship in question, as the code was denied due to a lack of relationship between the provider and 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 been met.Therefore, we decided that the Planhas to pay fordrug testing services (CPT 80307 and HCPCS G0482) provided to the enrollee on November 20, 2019.If the Plandoes 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/orsend 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultrasound provided on February 26, 2020 by an out of network (OON) provider. You asked the Plan to pay for an ultrasound. You say that you were never informed that you needed to use a specific facility. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that there are in-network facilities available for 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 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 an ultrasound provided on February 26, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral endoscopic sinus surgery to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve these OON services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services can be provided by a network provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve bilateral endoscopic sinus surgery 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 for antigen therapy services (95165) provided
on February 22, 2020.
You asked the Plan to waive the copayment for the antigen therapy services. You say that you would like
reconsideration because you were told there would not be a copayment for these services. The Plan denied your
request. The Plan says there is a $20 copayment per visit to a specialist.
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 specialist services.
You have been asked to pay a $20 copayment for the antigen therapy services. The antigen therapy falls within
the specialist 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 copayment for antigen
therapy services (95165) provided on February 22, 2020.
Your complaint about being provided with incorrect information about your copayment is not a valid appeal for
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does
not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 molecular pathology testing provided on October 2, 2019.
You asked the Plan to pay for Guardant360 molecular pathology 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 supported by the documentation.
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 Guardant360 molecular pathology testing is not supported in the medical record. Specifically, this service requires the reporting of CPT 81479. In addition, the appropriate DEX Z-Code identifier must be entered adjacent to the CPT code in the comments/narrative field. Based on this information, we decided that Medicare rules for coverage of Guardant360 molecular pathology testing have not been met. Therefore, we decided that the Plan does not have to pay for Guardant360 molecular pathology testing provided on October 2, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgery services and pay for the self-administered drugs provided on February 19, 2020 and March 4, 2020.
You asked the Plan to waive the copayment for the outpatient surgery services and pay for the self-administered drugs. You say that you were only told that you would have to pay a $250 copayment The Plan denied your request. The Plan says the claims have been processed correctly per your plan benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 copayment for outpatient surgery.
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. You have been asked to pay a $225 copayment for the outpatient surgery services and pay for the self-administered drugs. 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 outpatient surgery services and pay for the self-administered drugs provided on February 19, 2020 and March 4, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an MRI provided by an out-of-network provider on March 2, 2020.
You asked the Plan to waive the coinsurance for an MRI. You say that you were not aware that the provider was out-of-network. The Plan denied your request. The Plan says the correct coinsurance has been 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 40% coinsurance for outpatient diagnostic tests/radiological diagnostic services/out-of-network. You have been asked to pay a 40% coinsurance of the allowed amount for an MRI. The total allowed amount is $262.99. The total amount you are being asked to pay is $105.20 ($262.99 x 40% = $105.20). An MRI falls within the outpatient diagnostic tests/radiological diagnostic services/out-of-network 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 an MRI provided by an out-of-network provider on March 2, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).
You asked the Plan to pre-approve the Prolia. You say that Prolia is medically necessary. The Plan denied your request. The Plan says coverage for Prolia has already been approved under the enrollee's Part D coverage. In this case, it is not eligible for coverage under the Part B medical benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The medication at issue has already been approved under the enrollee's Part D drug coverage. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 and G0483 provided on October 28, 2019.
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 supported by the documentation.
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 CPT codes 80307 and G0483 are not supported in the medical record. Specifically, the documentation submitted did not include a physician order/lab requisition form or medical records stating exactly what tests were to be performed. 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 80307 and G0483 provided on October 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the specialist office visits provided on January 24, 2020 to February 17, 2020.You asked the Plan to waive the copayments for the specialist office visits. You say that you do not believe you owe the copayments for follow-up 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 $50 copayment for provider and professional services at an in-network specialist's office. You have been asked to pay a $50 copayment for each of the specialist office visits. The specialist office visits fall within the "Physician/Practitioner services, including doctor's office visits" benefit category. Please note, there is no provision in the contract which indicates a copayment would be waived if performed as a follow-up to a 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 specialist office visits provided on January 24, 2020 to February 17, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF services. You asked the Plan to pre-approve the SNF services. You say that you would like reconsideration because the SNF services are medically necessary. The Plan denied your request. The Plan says the member can safely receive the services they need in another setting. The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. 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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found this beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the medical eye exam and the routine eye exam provided on January 7, 2020.You asked the Plan to waive the copayment for the medical eye exam and the routine eye exam. You say that you are being charged two $10 copayments for the same visit.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 $10 copayment for visits to an in-network specialist for Medicare-covered exams to diagnose and treat diseases of the eye and a $10 copayment for in-network routine vision exams. You have been asked to pay a $10 copayment for the medical eye exam and a $10 copayment for the routine eye exam. The medical eye exam falls within the "Vision care (non-routine)" benefit category. The routine eye exam falls within the "Routine vision services" benefit category. The record shows a diagnosis of age-related cataracts which means you had a medical eye exam. The record also shows you were billed for a refraction which is considered a routine vision exam. 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 medical eye exam and the routine eye exam provided on January 7, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing services provided on June 24, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the billed codes cannot be verified.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. 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 forthe drug testing services provided on June 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on May 21, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency for 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 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 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 the medical services provided to the enrollee by an out-of-network provider on May 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the chemotherapy injections provided from January 16, 2019 to February 27, 2019.You asked the Plan to waive the coinsurance for the chemotherapy injections. You say that you do not understand why the charges are so high.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 20% coinsurance for in-network Medicare-covered Part B Chemotherapy drugs and other Part B drugs. You have been asked to pay a total of $3,200for the chemotherapy injections. The chemotherapy injections fall within the "Medicare Part B prescription drugs" 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 chemotherapy injections provided from January 16, 2019 to February 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for discharge day management (99217) provided on May 10,
2018.
You asked the Plan to pay for discharge day management. You say that you did not receive proper notice of the
enrollee's benefit determination. The Plan denied your request. The Plan says this was not filed timely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010
must be filed no later than one calendar year after the date of service.
The record shows that a claim for discharge day management was not filed until [enter date the claim was
filed]. This means that more than one calendar year from the date of service had passed before a claim was
filed. Therefore, we decided that the Plan does not have to pay for discharge day management (99217)
provided on May 10, 2018.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-ray and the bone length study
provided on February 5, 2020.
You asked the Plan to waive the copayment for the x-ray and the bone length study. You say that you do not
see in the Evidence of Coverage where a procedure or service by an in-network surgeon which would require a
$41.46 copayment and the insurance company pay nothing. 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 $5
copayment for in-network Medicare-covered x-rays and a $180 copayment for all other in-network Medicarecovered
diagnostic radiology services (not including x-rays). For this date of service, you have been asked to
pay the allowed amount of the claim because this amount is less than the $180 copayment for the bone length
study.
You have been asked to pay a $5 copayment for the x-ray and a $41.46 copayment for the bone length study.
The x-ray and the bone length study fall within the "Outpatient diagnostic tests and therapeutic services and
supplies" benefit category. The record shows the bone length study is considered a radiological 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 copayment for the x-ray and the bone length study provided on February 5,
2020.