Persius/hicric huggingface dataset:
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 
September 27, 2022. 
 
You asked the Plan to pay for the drug testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services billed are not supported. 
 
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 80307 is drug test(s), presumptive, any number of drug 
classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay 
[eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry 
either with or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, 
MALDI, TOF) includes sample validation when performed, per date of service. 
 
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 80307 and G0483 is not supported in the medical record. Specifically, the submitted 
medical records do include a physician's order; however, does not include a laboratory order for presumptive 
drug test(s) for any number of drug classes; therefore, code 80307 cannot be verified.  
 
The submitted medical records do include a physician's order; however, does not include laboratory order for 
presumptive drug test(s) for any number of drug classes; therefore, code G0483 cannot be verified. 
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 September 27, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to provide reimbursement for the laboratory services and the office visit provided 
on November 22, 2022. 
 
You asked the Plan to provide reimbursement for the lab services and the office visit. You say that you are 
requesting reimbursement. The Plan approved your request. The Plan says that this cost sharing was charged 
incorrectly. 
 
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 enrollees must pay a $0 copayment for outpatient diagnostic tests. Your 
contract with the Plan also says that enrollees must pay a $0 copayment for each office visit. 
 
The Plan says you must pay $53.13 towards your deductible for the lab services. The Plan also says that you 
must pay $117.36 towards your deductible for the office visit. According to the EOC, you do not have a 
deductible with the Plan. Based on the Plan contract, you are not responsible for a cost share amount for these 
services. Therefore, we decided the Plan does have to provide reimbursement for the lab services and office 
visit provided on November 22, 2022..   
 
If the Plan does 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/or send 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an urgent care visit provided on November 
16, 2022. 
 
You asked the Plan to reduce the copayment for an urgent care visit. You say that you went to the overflow 
office and was expecting to pay a $10 copayment. The Plan denied your request. The Plan says this cost 
sharing was charged 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 $45 
copayment for urgently needed services. 
 
You have been asked to pay a $45 copayment for an urgent care visit. This item/service falls within the 
urgently needed 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 reduce the copayment for an urgent 
care visit provided on November 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on November 15, 2022. 
 
You asked the Plan to pay for laboratory services. You say that the records attached support the services 
provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory services 
provided on November 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 18, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on October 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the dermatologist office visit provided on 
December 22, 2022. 
 
You asked the Plan to waive the copayment for the dermatologist office visit. You say that the specialist did 
not perform the procedure you were expecting. The Plan denied your request. The Plan says this cost sharing 
was charged 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 $40 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $40 copayment for the dermatologist office visit. This item/service falls within 
the physician/practitioner services, including doctors office visits 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 dermatologist office visit provided on December 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
December 13, 2022. 
 
You asked the Plan to pay for this dental service. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the service provided 
has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the service provided was exhausted on December 8, 2021.  Specifically, the Plans contract states that a comprehensive oral evaluation is covered once every 36 months. 
You previously received this service on December 8, 2021, less than 36 months prior, that was paid for by the 
Plan. Therefore, you have exhausted the allowable benefit for this service at this time. Therefore, we decided 
that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on December 13, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on December 14, 2022. 
 
You asked the Plan to pay for laboratory services. You say that the doctors office dailed to send in a 
preauthorization form for approval. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory services 
provided on December 14, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a custom fabricated abutment x4 and abutment supported crown 
x4 (D6057, D6058). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says that your benefit for the requested item or 
service has already been exhausted. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your benefit for the requested item or service was previously 
exhausted. Therefore, we decided that the Plan has to pre-approve a custom fabricated abutment x4 and 
abutment supported crown x4 (D6057, D6058).  
 
  If the Plan does 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/or send 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on April 6, 2022. 
 You asked the Plan to pay for ambulance services. You say that the enrollee was not in hospice on the date of 
service. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on April 5, 2022. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for ambulance services 
provided on April 6, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code G0483 provided on November 9, 2022. 
 
You asked the Plan to pay for procedure code G0483. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not supported. 
 
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 supported in the medical record. Specifically, the record shows that more than 
22 drug classes were tested, including Alcohol biomarkers, Alkaloids-not otherwise specified, Amphetamines, 
Antidepressants-tricyclic and other cyclicals, Antipsychotics-not otherwise specified, Barbiturates, 
Benzodiazepines, Buprenorphine, Cannabinoids-natural, Cannabinoids-synthetic, Cocaine, Fentanyls, 
Gabapentin-non-blood, Heroin metabolite, Methadone, Methylenedioxyamphetamines, Methylphenidate, 
Opiates, Opioids and opiate analogs, Oxycodone, Phencyclidine, Pregabalin, Sedative hypnotics (non-
benzodiazepines), Skeletal muscle relaxants, Stimulants-synthetic, Tapentadol, and Tramadol. Based on this 
information, we decided that Medicare rules for coverage of procedure code G0483 have been met. Therefore, 
we decided that the Plan has to pay for procedure code G0483 provided on November 9, 2022.  
 
If the Plan does 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/or send 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the arthrocentesis provided on November 
07, 2022. 
 
You asked the Plan to reduce the copayment for the arthrocentesis. You say that the copayment is too high for 
the service you received. The Plan denied your request. The Plan says this cost sharing was charged 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 $325 
copayment for outpatient surgery, including services provided at hospital outpatient facilities. 
 
You have been asked to pay a $325 copayment for the arthrocentesis. This item/service falls within the 
outpatient surgery, including services provided at hospital outpatient facilities 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 reduce the copayment for the arthrocentesis provided on November 07, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the urgent care visit provided on July 15, 
2022. 
 
You asked the Plan to reduce the copayment for the urgent care visit. You say that you had to go to urgent care 
because you could not see your primary care provider. The Plan denied your request. The Plan says this cost 
sharing was charged 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 $50 
copayment for urgently needed services. 
 
You have been asked to pay a $50 copayment for the urgent care visit. This item/service falls within the 
urgently needed 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 reduce the copayment for the urgent 
care visit provided on July 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service December 18, 2018. 
Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture (D5213).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on May 09, 2022. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan. You say that your 
maximum out-of-pocket has been met and you should not owe a copayment. The Plan denied your request. The 
Plan says this cost sharing was charged 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 $200 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $200 copayment for a computed tomography (CT) scan. This item/service falls 
within the outpatient diagnostic test 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. The maximum out-of-pocket was not met at the time the CT scan was rendered. 
Therefore, we decided that the Plan does not have to waive the copayment for a computed tomography (CT) 
scan provided on May 09, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a guided tissue regeneration, abutment supported 
retainer, custom fabricated abutment, and bone graft (D4266, D6104, D6069, D6057). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 a 
guided tissue regeneration, abutment supported retainer, custom fabricated abutment, and bone graft (D4266, 
D6104, D6069, D6057).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified oral surgery (D9999) procedure provided on 
June 17, 2022. 
 
You asked the Plan to pay for the dental service. You say that you were told that you would be reimbursed for 
$600 worth of dental services and you had extractions performed. The Plan denied your request. The Plan says 
the denial of payment for this service is correct, because the unspecified oral surgery or an extraction is not 
covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
unspecified oral surgery (D9999) procedure provided on June 17, 2022.  
 
Your complaint about your experience with the provider 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.