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

We decided that the Plan does not have to pay for the drug testing services (code G0483) you billed for date of service May 11, 2021.
You asked the Plan to pay for the drug testing services. You say that you have provided records, so you would like the claim reprocessed. The Plan denied your request. The Plan says the medical records do not support the number of drug classes test being reflected by the code billed.
The Plan must follow Medicare rules. Medicare rules say that in order to bill code G0483, there must be evidence of at least 22 drug classes tested. In this case, the records submitted indicate that only 19 drug classes were tested. Because testing of 22 classes is required to receive payment for G0483, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services (code G0483) you billed for date of service May 11, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting
from November 25, 2020, to December 1, 2020.

You asked the Plan to pay for the self-administered drugs. You say that the drugs should be covered. The Plan
denied your request. The Plan says the drugs you received are considered self-administered.

The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan
also says the drugs you received are not covered under Medicare 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 pay for the self-administered drugs
provided in an outpatient setting from November 25, 2020, to December 1, 2020.

Benefits for the self-administered drugs 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drug provided in an outpatient setting on June 16, 2021.
You asked the Plan to pay for the self-administered drug. You say that this should be covered. The Plan denied your request. The Plan says the drug you received is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drug you received is not covered under Medicare 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 pay for the self-administered drug provided in an outpatient setting on June 16, 2021.
Benefits for the self-administered 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental fillings you received on July 29, 2021.

You asked the Plan to pay for the fillings. You say that the chemotherapy caused the cavities. The Plan denied your request. The Plan says this is not a covered 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 services are not among those covered under this benefit. The Plan covers only those dental services listed in the Evidence of Coverage. Dental fillings are not covered. Therefore, we decided that the Plan does not have to pay for the dental fillings you received on July 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Omidria injection you received on August 17, 2021.
You asked the Plan to waive the coinsurance for the Omidria injection. You say that you were told that your $225 copayment would cover everything. The Plan denied your request. The Plan says you were charged this coinsurance correctly.
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 Medicare Part B drugs. You have been asked to pay 20% coinsurance for the Omidria injection. The Omidria injection falls within the Medicare Part B drugs benefit category. This coinsurance is a separate charge from any office visit or surgery copayment that may apply. 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 Omidria injection you received on August 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intravenous moderate (conscious) sedation/analgesia- first 15 minutes (D9239), intravenous moderate (conscious) sedation/analgesia - each subsequent 15-minute increment (D9243), extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140), and extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) provided November 19, 2020.
You asked the Plan to pay for the intravenous sedation/analgesia and tooth extractions. You say that you believed these services would be covered under your medical benefits. The Plan denied your request. The Plan says these services are not covered under your benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
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 intravenous moderate (conscious) sedation/analgesia- first 15 minutes (D9239), intravenous moderate (conscious) sedation/analgesia - each subsequent 15-minute increment (D9243), extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140), and extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) provided November 19, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for self-administered drugs (A9270) provided from July 19, 2021, to July 22, 2021.
You asked the Plan to pay for self-administered drugs. You say that this was part of a hospital stay. The Plan denied your request. The Plan says coverage of these medications is the responsibility of your prescription drug plan.
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 pay for self-administered drugs (A9270) provided from July 19, 2021, to July 22, 2021.
Benefits for self-administered drugs 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot inserts provided on April 12, 2021.
You asked the Plan to pay for foot orthotics. You say that the arthritis in your feet is causing pain. The Plan denied your request. The Plan says this item is not a covered benefit for your condition.
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. We looked at the file and the rules. The records do not show that you 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 pay for foot inserts provided on April 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a cystourethroscopy, with removal of a
ureteral stent rendered on May 26, 2021.
You asked the Plan to waive the copayment for a cystourethroscopy, with removal of a ureteral stent. You say
that this was a follow up surgery performed after the main surgery to remove a kidney stone on May 18, 2021.
You also say that the charges are just as high as the initial surgery. You also say the follow up procedure was
necessary to remove a stent. The Plan denied your request. The Plan says you were 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 $380
copayment for Medicare-covered outpatient surgery in an outpatient hospital setting.
You have been asked to pay a $380 copayment for a cystourethroscopy, with removal of a ureteral stent.
A cystourethroscopy, with removal of a ureteral stent falls within the Outpatient Surgery, including services
provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 a cystourethroscopy, with removal of a ureteral stent rendered on
May 26, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services you had on May 18, 
2021. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that this was an internal 
transfer from a hospital to a nursing facility.  You said that the hospital would not let your daughter transport 
you and said there would be no charge. The Plan denied your request. The Plan says you were charged this 
copayment correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment per trip for ambulance services.  
 
You have been asked to pay a $90 copayment per trip for the ambulance services. This copayment applies 
every time you are transported, regardless of the reason. 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 ambulance services you had on May 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic mammogram with breast 
tomosynthesis you had on July 14, 2021. 
 
You asked the Plan to waive the copayment for the diagnostic mammogram. You say that you do not feel as 
though you should have to pay a copayment for your yearly mammogram. The Plan denied your request. The 
Plan says you were charged this copayment correctly. 
 
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 $60 
copayment for x-rays.  
 
The Plan contract says that a screening mammogram is used for the early detection of breast cancer in women 
who have no signs or symptoms of the disease.  Once a history of breast cancer has been established, and until 
there are no longer any signs or symptoms of breast cancer, ongoing mammograms are considered diagnostic 
and subject to cost sharing.  Records show that you have a history of breast cancer, so the diagnostic testing 
copayment applies. You have been asked to pay a $60 copayment for the diagnostic mammogram. The 
diagnostic mammogram falls within the x-rays 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 diagnostic mammogram with breast tomosynthesis you had on July 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0482, 80307) provided on June 14, 2021.
You asked the Plan to pay for drug testing. You say that this was medically necessary. The Plan denied your request. The Plan says this is not supported in the records.
The Plan must follow Medicare rules. Medicare rules say that criteria to establish medical necessity for drug testing must be based on patient-specific elements identified during the clinical assessment, and documented by the clinician in the patient's medical record. We looked at the file and Medicare rules. The submitted medical records do not include documentation showing that the testing at issue was medically necessary. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (G0482, 80307) provided on June 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the elastic compression stockings that were provided on March 29, 2021.
You asked the Plan to pay for the compression stockings. You say that these were prescribed by your vascular surgeon. The Plan denied your request. The Plan says the compression stockings do not meet the requirements for approval.
The Plan must follow Medicare rules. The rules say that elastic stockings are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the elastic compression stockings that were provided on March 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the visit you had with a gastroenterologist on June 23, 2021.
You asked the Plan to waive the deductible for the gastroenterology visit. You say that you do not understand why this claim was not paid. The Plan denied your request. The Plan says you had not yet met your deductible at the time of these services.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $500 deductible which applies to specialist services. The gastroenterology visit falls within the benefit category of specialist services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible which applies to specialist services. This cost sharing is a contractual obligation that had not been met at the time the gastroenterology visit was received on June 23, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the visit you had with a gastroenterologist on June 23, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion services (99601) provided April 22, 2021. 
 
You asked the Plan to pay for the home infusion services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the claim cannot be paid 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. 
 
We find that CPT code 99601 is not supported in the medical record. Specifically, per the National Physician 
Fee Schedule, the billed code has a status of "I" and is not eligible for separate payment. Based on this 
information, we decided that Medicare rules for coverage of the home infusion services have not been met. 
Therefore, we decided that the Plan does not have to pay for home infusion services (99601) provided April 22, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a second pair of eyeglasses provided on April 20, 2021.

You asked the Plan to pay for a second pair of eyeglasses. The Plan denied your request. The Plan says you obtained a frame and single vision lenses on March 17, 2021, which exhausted your vision benefit.

Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers one pair of standard eyeglass frames and standard plastic eyeglass lenses per calendar year. 

We looked at the file and the Plan's rules. The file shows that you obtained eyeglasses on March 17, 2021, and you have exhausted your vision benefit. Therefore, we decided that the Plan does not have to pay for a second pair of eyeglasses provided on April 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out of network physician services.
You asked the Plan to pre-approve out of network physician services. You say that you prefer to see the requested provider as he was recommended by friends. The Plan denied your request. The Plan says this provider is not in 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 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 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 out of network physician services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the re-cement or re-bond crown (D2920) provided June 24, 2021.
You asked the Plan to pay for the re-cement or re-bond crown. You say that the crown was covered initially so you do not understand why the recementing is not covered. The Plan denied your request. The Plan says this service is not covered under your benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 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 re-cement or re-bond crown (D2920) provided June 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on June 23, 2021. 
 
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 an appropriate modifier was not 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, we have confirmed that code 70480 
is a column II code to column I code 70450. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for imaging services provided to the enrollee on June 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator.
You asked the Plan to pre-approve this equipment. You say that you need a portable oxygen concentrator for use outside of the home for appointments. The Plan denied your request. The Plan says Medicare does not cover oxygen equipment for use outside of the home.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services (98940) provided on June 14, 2021, 
through June 24, 2021. 
 
You asked the Plan to pay for the chiropractic services. You say that you would like reconsideration because 
claims from this provider have been paid in the past. The Plan denied your request. The Plan says chiropractic 
maintenance is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care.  
 
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 chiropractic services. Our reviewer says 
that the records do not indicate that clinical improvement is occurring or can be reasonably expected from 
ongoing care. Our physician reviewer found the records provided support that the requested care is chiropractic 
maintenance. 
 
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 chiropractic services have not been met. Therefore, we decided that the Plan 
does not have to pay for chiropractic services (98940) provided on June 14, 2021, through June 24, 2021.