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

We decided that the Plan does not have to pay for drug testing (G0483) provided on April 29, 2021.
You asked the Plan to pay for drug testing. You say that this was billed correctly. The Plan denied your request.
The Plan says this code is 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 drugspecific
calibration and matrix-matched quality control material (e.g., to control for instrument variations and
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or
more drug class(es), including metabolite(s) if performed.
We find that CPT code G0483 is not supported in the medical record. Specifically, the records show that only
20 drug classes were tested. 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 (G0483)
provided on April 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified preventative procedure (D1999) provided on
August 31, 2021.
You asked the Plan to pay for the unspecified preventative procedure. You say that your dental benefit covers
up to $2,000 of dental care, which you have not used up this year. You do not understand why this service is
denied. The Plan denied your request. The Plan says this service is not covered by your dental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
unspecified preventative procedure (D1999) provided on August 31, 2021.
Appeal type: Outpatient Therapies
Decision: Partially Favorable

We decided that the Plan has to reduce the cost-sharing charges for PT. We decided that the Plan does not have
to reduce the cost-sharing charges for PT to the amount you requested.
You asked the Plan to reduce the cost-sharing charges for PT. You say that you were told that you would not
owe anything for the visits. The Plan says that the claims were processed correctly, and you are being charged
the correct amount.
We decided that the Plan has to reduce the cost-sharing charges for PT from $315 to $225.
Your contract with the Plan clearly says that you must pay a $25 copayment for PT.
The Plan says that you must pay a $35 copayment for PT. However, based on your contract with the Plan, you
cannot be asked to pay more than a $25 copayment for PT. Therefore, we decided that the Plan has to reduce
the cost-sharing charges for PT from $315 to $225.
We also decided that the Plan does not have to reduce the cost-sharing charges for PT to the amount you
requested.
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 PT.
You received PT from July 23, 2021, to August 20, 2021, for a total of 9 visits. Therefore, you are responsible
to pay a $25 copayment per each visit. The total amount you owe is: $25 (copayment) x 9 (PT visits) = $225.
Therefore, we decided that the Plan does not have to reduce the cost-sharing charges for PT to the amount you
requested.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (87426) provided August 7, 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 the testing was for travel purposes and was screening in nature and is noncovered.
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, COVID-19 testing, 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
lab services (87426) provided August 7, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement of a peri-implant defect or defects surrounding a single implant, and surface cleaning of the exposed implant surfaces, including flap entry and closure (D6101) provided July 7, 2021.
You asked the Plan to pay for the debridement of a peri-implant defect or defects surrounding a single implant. You say that this treatment was necessary, and you are unable to pay the bill without help. 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 debridement of a peri-implant defect or defects surrounding a single implant, and surface cleaning of the exposed implant surfaces, including flap entry and closure (D6101) provided July 7, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a positron emission tomography (PT) computed tomography (CT) scan from skull to mid-thigh.
You asked the Plan to pre-approve a PET CT scan from skull to mid-thigh. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary. 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 a PET CT scan from skull to mid-thigh. Our reviewer says that the services are medically necessary. Our physician reviewer found the requested Axumin scan is prostate specific and will thus enable clinicians to determine if the skeletal findings are related to prostate cancer. Obviously, this determination will greatly impact clinical management. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a PET CT scan from skull to mid-thigh have been met. Therefore, we decided that the Plan has to pre-approve a positron emission tomography (PT) computed tomography (CT) scan from skull to mid-thigh.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting from August 15, 2020, to August 25, 2020.
You asked the Plan to pay for the self-administered drugs. You say that you were rushed to the hospital due to severe stomach pain and uncontrollable vomiting.
You say that you were administered medication to control your symptoms. You say that you did not request any medications or administer them yourself. You also say that you do not understand why you are being charged for medication that was ordered by the doctors and administered by staff. 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 August 15, 2020, to August 25, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam (92004) provided on May 10, 2021.
You asked the Plan to waive the copayment for the eye exam. You say that this was your annual routine eye exam and should have been processed with a $0 copayment. The Plan denied your request. The Plan says this claim was processed correctly, and your copayment was assessed in accordance with your contract.
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 Medicare-covered vision services provided in a specialist's office. You have been asked to pay a $45 copayment for the eye exam. The eye exam in question was billed with medical diagnoses, and therefore is a medical eye exam rather than 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 eye exam (92004) provided on May 10, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 3 home health skilled nursing visits.
You asked the Plan to pre-approve 3 home health skilled nursing visits. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.
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 3 home health skilled nursing visits. Our reviewer says that the services are not medically necessary. Our physician reviewer found based on the medical records provided there is no documentation that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. Records do not document any acute or unstable medical conditions or changes in medication or treatment which would necessitate any further skilled nursing visits beyond what have already been approved. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 3 home health skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 3 home health skilled nursing visits
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a 4K score test for prostate cancer (81539) provided on July
6, 2021.
You asked the Plan to pay for the 4K score test. You say that the enrollee was recommended for a 4K score test
because they have benign prostatic hypertrophy and elevated prostate-specific antigen (PSA). The Plan denied
your request. The Plan says he criteria for coverage of the 4K score test are not met, and this service was not
medically necessary per Medicare guidelines.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are 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 pay for the 4K score test. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the enrollee's PSA was shown to be greater than 10, which means that it is outside the range of
the Medicare coverage criteria for medical necessity.
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 4K score test have not been met. Therefore, we decided that the Plan does
not have to pay for a 4K score test for prostate cancer (81539) provided on July 6, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for diabetic shoes purchased out of network on April 5, 2021.
You asked the Plan to pay for these shoes. You say that you did not know you had to use a network provider
and the vendor refused to ask for prior authorization. The Plan denied your request. The Plan says you did not
have prior authorization for these shoes which is required both in and out of network.
Medicare rules say that plans can require enrollees to get prior authorization. The contract with the Plan says
that durable medical equipment requires prior authorization. This provider was not in network. You did not
have prior authorization. The provider told you they would not ask for prior authorization, but you chose to
proceed with the purchase. Therefore, we decided that the Plan does not have to pay for diabetic shoes
purchased out of network on April 5, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for outpatient rehabilitation services on February 24, 2021.
You asked the Plan to waive the coinsurance for outpatient rehabilitation services. You say that the treatment did not help and your condition is the same. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 50% coinsurance for out-of-network outpatient rehabilitation services. You received outpatient rehabilitation services from an out-of-network provider on February 24, 2021. Therefore, you are responsible to pay your share of the out-of-network cost-sharing charges. The total allowed amount is $125.30 and 50% of that is $62.65. You have been asked to pay the total coinsurance amount of $62.65 for outpatient rehabilitation services.
Outpatient rehabilitation services fall within the outpatient rehabilitation services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for outpatient rehabilitation services on February 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for bitewings (D0274), a comprehensive oral evaluation
(D0150), a prophylaxis (D1110) provided by an out-of-network provider on June 14, 2019.
You asked the Plan to pay for bitewings, a comprehensive oral evaluation, a prophylaxis. You say that you
were misinformed and told that this dentist was in-network. The Plan denied your request. The Plan says you
are responsible for 100% of services provided by an out-of-network provider.
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.
When services are provided by an out-of-network dentist, the enrollee is responsible for 100% of the allowed
amount. Therefore, we decided that the Plan does not have to pay for bitewings (D0274), a comprehensive oral
evaluation (D0150), a prophylaxis (D1110) provided by an out-of-network provider on June 14, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Procrit.
You asked the Plan to pre-approve Procrit. You say that the medication is necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
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 Procrit. Our reviewer says that the
medication is not medically necessary. Our physician reviewer found the documentation does not support that
Retacrit would likely be less effective, and/or would likely have adverse effects for the enrollee in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Procrit have not been met. Therefore, we decided that the Plan does not have to
pre-approve Procrit
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response without transport provided on April 14, 2021, billed with code A0429-QL.
You asked the Plan to pay for the ambulance services. You say that the BLS rate should be paid as the enrollee was not pronounced dead until after the ambulance was called. The Plan denied your request. The Plan says Medicare rules require that the non-emergency ambulance code A0428 be used for situations where the enrollee passes away prior to ambulance arrival on the scene.
The Plan must follow Medicare rules. Medicare rules say that providers must use code A0428 with modifier -QL for ambulance services where the enrollee passes away after dispatch but prior to arrival.
In this case, the claim was billed with code A0429 which is not appropriate for this billing situation. Therefore, we decided that the Plan does not have to pay for the ambulance response without transport provided on April 14, 2021, billed with code A0429-QL.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to pay for an over the bed table purchased for the enrollee on June 9, 2021.
You asked the Plan to pay for this item. You say that the enrollee is bed bound and needs this table to eat and function. The Plan denied your request. The Plan says over the bed tables are not covered by Medicare.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. An over the bed table does not serve a purpose that is primarily medical in nature. This item is available to the public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for an over the bed table purchased for the enrollee on June 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown - porcelain fused to noble metal (D2752), core
buildup, including any pins when required (D2950), and resin-based composite - two surfaces, posterior
(D2392) provided June 4, 2021.
You asked the Plan to pay for the crown, core buildup and resin-based composite. You say that you expected
the Plan to pay for your services. The Plan denied your request. The Plan says the crown and core buildup is
not covered under your benefits. The resin-based composite has been covered with 50% coinsurance.
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 resin-based
composites provided by a network provider with 50% coinsurance.
We looked at the file and Medicare rules. In this case the Plan provided documentation showing that the resinbased
composite was covered by the Plan and you were responsible for 50% of the cost. Though the Plan offers
a dental benefit in excess of Medicare coverage, the crown and core buildup are not among those covered under
this benefit. Therefore, we decided that the Plan does not have to pay for the crown - porcelain fused to noble
metal (D2752), core buildup, including any pins when required (D2950), and or provide additional payment for
the resin-based composite - two surfaces, posterior (D2392) provided June 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to make additional payment for the spinal manipulation, office visit evaluation, and imaging services provided by a chiropractor on July 2, 2021.
You asked the Plan to make additional payment for the services provided by a chiropractor. You say that you paid out of pocket and feel that the provider should refund you. The Plan denied your request. The Plan says the provider agreed to refund the amount in excess of your responsibility of $144. The remainder is your cost share for the manipulation and noncovered services.
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 record shows that you have been asked to pay a $20 copayment for the chiropractic manipulation of the spine. The records show that the other services at issue are not manual manipulation of the spine.
Therefore, we decided that the Plan does not have to make additional payment for the spinal manipulation, office visit evaluation, and imaging services provided by a chiropractor on July 2, 2021.