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

We decided that the Plan does not have to pay for a pharmacogenomics testing panel (Factor V Leiden, Factor
II prothrombin, MTHFR, CYP2D6, CYP2C19, CYP3A4, CYP3A5, and VKORC1) provided on June 5, 2021.
You asked the Plan to pay for pharmacogenomics testing. You say that you are appealing with supporting
records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because
this testing remains investigational.
The Plan follows Medicare rules. Medicare rules state that Factor V Leiden, Factor II prothrombin, and
MTHFR testing are considered investigational. Medicare rules state that pharmacogenomics testing may be
covered under certain conditions.
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 pharmacogenomics testing. Our reviewer
says that this testing does not meet the criteria for payment. Our physician reviewer found there was
insufficient support for this request. There were no planned changes in treatment expected based on these
genetic tests and no indication that medications would be changed for her conditions based on the results.
There is insufficient evidence to show that these tests lead to improved overall cardiovascular outcomes
compared to the standard of care. Therefore, this request for pharmacogenomic testing is considered not
medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of pharmacogenomics testing have not been met. Therefore, we decided that the
Plan does not have to pay for a pharmacogenomics testing panel (Factor V Leiden, Factor II prothrombin,
MTHFR, CYP2D6, CYP2C19, CYP3A4, CYP3A5, and VKORC1) provided on June 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified preventive procedure, by report (D1999) provided September 1, 2021.

You asked the Plan to pay for the unspecified preventive procedure. You say that you would like the service 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 unspecified preventive procedure, by report (D1999) provided September 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) and intraoral - complete series of radiographic images (D0210) provided August 9, 2021, by an out-of-network (OON) dentist.

You asked the Plan to pay for the comprehensive exam and intraoral x-rays. You say that you got the name of the dentist from the Plan saying he was covered. The Plan denied your request. The Plan says these services were not provided by a participating dentist and there is no record that you contact the Plan regarding contracted dental providers.

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. The Plan does not cover services performed by a non-participating dentist. 

We looked at the file and Medicare rules. 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. Based on this information, we decided that the Plan's rules for coverage of the comprehensive exam and intraoral x-rays have not been met. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) and intraoral - complete series of radiographic images (D0210) provided August 9, 2021, by an out-of-network (OON) dentist.

Your complaint about potentially being provided misinformation about network dentists 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the extraction, erupted tooth or exposed root (elevation
and/or forceps removal) (D7140) and intraoral - periapical first radiographic image (D0220) September 20,
2021.
You asked the Plan to pre-approve the tooth extraction and periapical x-ray. You say that you have dental
coverage and feel the services should be covered. 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 pre-approve the
extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) and intraoral - periapical
first radiographic image (D0220) September 20, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 7, 2021.

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 testing is not covered.

The Plan must follow Medicare rules. The rules say that urinalysis is the standard of care for UTI.

We looked at the file and Medicare rules. The file shows that the services at issue exceeded the standard of care 
for the diagnosis and treatment of a UTI. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on July 7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 87640, 87651, 87653, 87798, 88312) provided to the enrollee on June 16, 2021.

You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. A special stain, immunohistochemistry stain, or immunocytochemistry stain must meet certain diagnosis and documentation guidelines to be reported. There are diagnosis and service requirements that must be documented in the available patient data to explain and support multiple infectious detection tests for common nail/feet concerns. Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s): 87640, 87651, 87653, 87798, 88312) provided to the enrollee on June 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for office visits (99213, 99214) rendered from
April 4, 2021, to April 5, 2021.
You asked the Plan to waive the copayments for office visits. You say that you were admitted to the hospital
for those days, and that this was not outpatient. The Plan denied your request. The Plan says you were charged
the correct copayment 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 $35
copayment for each physician specialist visit for Medicare-covered services.
You have been asked to pay a $35 copayment for each of two office visits, which is a total of $70 ($35
copayment x 2 office visits = $70). The record shows these visits were during outpatient observation. 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 office visits (99213, 99214) rendered from April 4, 2021,
to April 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit (99203) provided on September 14, 2021.

You asked the Plan to waive the copayment for the specialist office visit. You say that the services should be covered as they were deplorable. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services rendered.

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 Physician/Practitioner services, including doctor's office visits, specifically specialist visits.

You have been asked to pay a $50 copayment for the specialist office visit. The record indicates that these services were performed by a dermatologist. 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 specialist office visit (99203) provided on September 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for special stain including interpretation and report; Group I for
microorganisms (eg, acid fast, methenamine silver) (CPT code 88312) provided to the enrollee on December
10, 2020.
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request.
The Plan says the service is not supported by the records.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the service have not been met. A special stain,
immunohistochemistry stain, or immunocytochemistry stain must meet certain diagnosis and documentation
guidelines to be reported. The documentation submitted does not meet the above-mentioned Medicare
documentation requirements for special stains. Therefore, we decided that the Plan does not have to pay for
special stain including interpretation and report; Group I for microorganisms (eg, acid fast, methenamine
silver) (CPT code 88312) provided to the enrollee on December 10, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on June 7 to August 4, 2021.

You asked the Plan to pay for psychotherapy services. You say that you tried to secure appointments with in-network providers in your local area to no avail. The Plan denied your request. The Plan says rules for payment have not been met because the provider of the services at issue has opted out of Medicare.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. 

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for psychotherapy services provided on June 7 to August 4, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service, advanced life support, emergency transport, level 1 (A0427) and ground mileage (A0425) provided October 9, 2020.
You asked the Plan to waive the copayment for the emergency ambulance services. You say that you feel there should be a $0 copayment because you were diagnosed with coronavirus (COVID-19). The Plan denied your request. The Plan says transportation service copayments are not part of the cost sharing waiver for COVID-19 diagnosis and testing. The copayment was applied 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 $275 copayment for each Medicare-covered one-way trip via ground ambulance. You have been asked to pay a $275 copayment for the emergency ambulance services. The emergency
ambulance services falls within the Ambulance 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 the ambulance service, advanced life support, emergency transport, level 1 (A0427) and ground mileage (A0425) provided October 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for labs services (G0452) provided August 30, 2021.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says this test was ordered for screening purposes and is non-covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered.

The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for labs services 
(G0452) provided August 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the screening mammogram and breast tomosynthesis rendered on March 24, 2021.  

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 are not covered.  

The Plan must follow Medicare rules. The rules say that payment may be made for only one screening mammography performed on a woman over age 34, but under age 40, performed after at least 11 months have passed following the month in which the last screening mammography was performed.  

We looked at the file and Medicare rules. The file shows that you received a screening mammogram on August 25, 2020 that was covered by the Plan. The screening mammogram on April 16, 2021 was performed less than 11 months from the services on August 25, 2020. Therefore, we decided that the Plan does not have to pay for the screening mammogram and breast tomosynthesis rendered on March 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140), cone beam computed tomography (CT) capture and interpretation with limited field of view - less than one whole jaw (D0364), and incomplete endodontic therapy; inoperable, unrestorable or fractured tooth (D3332) provided August 5, 2021.

You asked the Plan to pay for the limited oral exam, cone beam CT scan and incomplete root canal. You say that these services were not elective, they were medically necessary. The Plan denied your request. The Plan says you have exceeded the frequency limit for the limited oral exam and the remaining 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. The Plan covers the limited oral exam once per plan year. 

We looked at the file and Medicare rules. The Plan provided documentation showing that a limited oral exam was previously covered on June 17, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of the limited oral exam has been exceeded. Though the Plan offered dental benefits in excess of Medicare coverage, the cone beam CT scan and incomplete root canal are not among those covered services. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140), cone beam computed tomography (CT) capture and interpretation with limited field of view - less than one whole jaw (D0364), and incomplete endodontic therapy; inoperable, unrestorable or fractured tooth (D3332) provided August 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the supplies provided on May 18, 2021.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the services are always bundled into payment for other services.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

In this case, the CPT Code Manual definition of code 99072 is additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease. 

We find that CPT code 99072 is a bundled code. When these services are covered, payment for them is subsumed by the payment for the services to which they are incident. 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 supplies provided on May 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an immediate lower denture (D5140) and eight (8) teeth extractions (D7140) provided on September 14, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for an immediate lower denture and 8 teeth extractions. You say that you would like to request a reconsideration of the denial on this claim. You also say you have never had any issues with the Plan. The Plan denied your request. The Plan says the requested provider has opted out of Medicare.

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. We have confirmed that the provider opted out of Medicare on January 29, 2018. This means the provider was opted out of Medicare for the date of service at issue. Therefore, we decided that the Plan does not have to pay for an immediate lower denture (D5140) and eight (8) teeth extractions (D7140) provided on September 14, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for manual therapy techniques (97140) provided January 21, 2021 to February 18, 2021.

You asked the Plan to pay for the chiropractic services. You say that the Plan had been paying for chiropractic coverage in the past. You have been making progress in avoiding drugs and surgery. Please reconsider compensating the doctor for his services. The Plan denied your request. The Plan says this service is not a covered benefit.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for manual therapy techniques (97140) provided January 21, 2021 to February 18, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on March 2, 2021.

You asked the Plan to pay for the services provided. You say that there is no contract that indicates the codes 
are included in the dialysis rate. The Plan denied your request. The Plan says the lab tests are the responsibility 
of the dialysis center.

The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for
the lab services provided on March 2, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cytopathology, in situ hybridization (eg, FISH), urinary 
tract specimen with morphometric analysis, 3-5 molecular probes, each specimen; manual (CPT code 88120) 
provided to the enrollee on May 11, 2021.

You asked the Plan to pay for the service. You say that as per medical records diagnosis Z79.891 is correctly 
linked with 88120. The Plan denied your request. The Plan says the service is not covered as billed.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered.

The test at issue in this appeal, the service, was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Diagnosis: Z79.891 Long term (current) use of opiate analgesic 
Cystoscopy in conjunction with bladder tumor markers is standard practice to evaluate patients with symptoms 
suggesting bladder cancer and to monitor treated patients for recurrence or progression. Bladder cancer tumor 
markers performed by any technology immunoassay, molecular or FISH testing, are not covered for screening 
of all patients with hematuria. Bladder tumor markers are not expected to be performed until other diagnostic 
studies fail to identify the etiology of the hematuria. Urine cytology is not considered a bladder tumor marker. 
FISH testing is intended for use, in conjunction with and not in lieu of current standard diagnostic procedures, 
as an aid for initial diagnosis of bladder carcinoma in patients with [gross] hematuria, and subsequent 
monitoring for tumor recurrence in patients previously diagnosed with bladder cancer. Therefore, we decided 
that the Plan does not have to pay for the cytopathology, in situ hybridization (eg, FISH), urinary tract 
specimen with morphometric analysis, 3-5 molecular probes, each specimen; manual (CPT code 88120) 
provided to the enrollee on May 11, 2021.