Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the infusion services provided on February 
18, 2020 and March 10, 2020. 
 
You asked the Plan to waive the coinsurance for the infusion services. You say that you feel you should not be 
responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied 
your request. The Plan says you received infusion therapy services on the dates of service at issue in this 
appeal. The Plan says that the correct coinsurance has applied per your contract with the Plan. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Medicare Part B prescription drugs.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received infusion therapy 
services provided in an outpatient hospital setting on February 18, 2020 and March 10, 2020. You have been 
asked to pay a 20% coinsurance for each infusion therapy service, totaling $494.08 on February 18, 2020 and 
$507.39 on March 10, 2020. The infusion therapy services fall within the Medicare Part B prescription drugs 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the coinsurance for the infusion services provided 
on February 18, 2020 and March 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services rendered by the out of network (OON) 
provider on April 28, 2020 and April 30, 2020. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
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 in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We 
found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan 
does not have to pay for the medical services rendered by the out of network (OON) provider on April 28, 2020 
and April 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on January 17, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for clinic visit and laboratory tests. You say that you are appealing with medical 
records. The Plan denied your request. The Plan says the denial of payment for these services is correct, 
because this provider is out-of-network with the Plan and authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical services provided on January 17, 2020 
by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug test (G0483) rendered by the out of network (OON) 
provider on December 4, 2019. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the drug test (G0483) rendered by the out of network (OON) provider on December 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on March 14, 2020. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were not 
billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be reported with one 
unit of CPT 81479 and the appropriate DEX Z-Code.  
 
We looked at the file and Medicare rules. The requested Guardant360 testing was billed with multiple CPT 
codes. Per the applicable article, this testing must be reported with CPT 81479 and the appropriate DEX Z-
Code. 
 
Based on this information, we decided that Medicare rules for coverage of the testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on March 14, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for massage therapy (97124), electrical stimulation (97014), and 
hot or cold pack application (97010) provided by a chiropractor on February 11, 2020 to February 25, 2020. 
 
You asked the Plan to pay for massage therapy, electrical stimulation, and hot or cold pack application. You 
say that without these treatments you would be unable to walk. The Plan denied your request. The Plan says 
these services are not covered by Medicare or the Plan. 
 
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 massage therapy (97124), electrical stimulation (97014), and hot or cold pack 
application (97010) provided by a chiropractor on February 11, 2020 to February 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an automatic external defibrillator 
provided on July 5, 2019. 
 
You asked the Plan to waive the coinsurance for an automatic external defibrillator. You say that you returned 
the vest July 8, 2019 and feel that you should not owe coinsurance for the entire month. 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 5% 
coinsurance for DME and related supplies.  
 
You received an automatic external defibrillator on July 5, 2019. The allowed amount is $2,174.63 and 5% of 
that is $108.73.  
 
You have been asked to pay the total coinsurance amount of $108.73 for an automatic external defibrillator. An 
automatic external defibrillator falls within the DME and related supplies benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the coinsurance for an automatic external defibrillator provided on July 5, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered from December 17, 2019
to February 4, 2020.
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 that home infusion services and supplies may be
covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The
Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies.
We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare
and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does
not have to pay for the home infusion therapy rendered from December 17, 2019 to February 4, 2020.
Benefits for these services 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 periodic oral evaluation and prophylaxis provided on 
January 13, 2020. 
 
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you were not made 
aware, in a timely manner, of the new Medicare policy. The Plan denied your request. The Plan says you 
received these dental services from an opt out provider. 
 
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. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
the periodic oral evaluation and prophylaxis provided on January 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment for the office visit (99204) provided on 
February 6, 2020. 
 
You asked the Plan to adjust the copayment for this service. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied 
correctly to the service provided. 
 
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 physician services provided in a specialist's office.  
 
You have been asked to pay a $45 copayment for the physician services provided in a specialist's office. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. The record 
shows that you have issued a $40 payment to the provider, therefore your remaining amount owed is $5.00. 
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 adjust the copayment for the office visit (99204) provided on February 6, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for diabetic supplies provided on February 10, 
2020. 
 
You asked the Plan to waive the deductible for diabetic supplies. You say that you disagree with the charges 
because you were told that diabetic supplies would not be subject to the annual deductible. The Plan denied 
your request. The Plan says the claims were processed correctly and the enrollee is being charged the correct 
amount. 
 
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 for diabetes self-monitoring supplies. Medicare-
covered diabetic monitoring supplies received from a pharmacy do not apply to your combined annual 
deductible. 
 
The enrollee received diabetic supplies on February 10, 2020 from a durable medical equipment company. 
Since the enrollee did not receive diabetic supplies from a pharmacy, the annual deductible does apply. The 
record shows that the enrollee had only paid $30.72 toward the $500 deductible prior to receiving the diabetic 
supplies. Therefore, the enrollee is responsible to pay the remaining deductible balance of $469.28.   
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category diabetes 
self-monitoring supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is a $500 deductible for diabetes self-monitoring supplies. This cost sharing is a contractual obligation that had 
not been met at the time diabetic supplies were received on February 10, 2020. Therefore, we decided that the 
Plan does not have to waive the deductible for diabetic supplies provided on February 10, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on April 4, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the OON lab testing. You say that the lab provided the testing that was ordered 
by the physician and should be paid. The Plan denied your request. The Plan says this testing was ordered by 
an out of network provider and there are network providers available. 
 
Medicare rules say that plans can require enrollees to get care from network providers.  
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the lab testing provided on April 4, 2020 by an out 
of network (OON) provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for genetic testing provided on August 9, 2019. 
 
You asked the Plan to pay for genetic test. You say that this test is covered by Medicare and was ordered by the 
enrollee's treating physician. The Plan denied your request. The Plan says that the denial of payment for this 
service is correct. 
 
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. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a 
contract provider are considered approved by the plan unless notice is provided that the services will not be 
covered. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not specify whether the ordering physician was in-network or out-
of-network with the Plan. The documentation submitted does not include prior notice from the Plan that this 
testing would not be covered. Without this information, we cannot determine whether the lab order made 
constituted plan-directed care. Therefore, the Plan has not shown that its decision to deny payment is correct or 
justified according to Medicare rules. Therefore, we decided that the Plan has to pay for genetic testing 
provided on August 9, 2019.  
 
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 pay for vision care services provided on January 10, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for vision care services.
You say that it is the doctor's responsibility to get the prior authorization. The Plan denied your request. The 
Plan says prior authorization was not obtained. The Plan says that the member's primary care physician did not 
refer these services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for vision care services provided on January 10, 2020 
by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab work provided on February 27, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for lab work. You say that you were given incorrect insurance information at first. 
You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. 
The Plan says prior authorization was not obtained. The Plan says that the member's primary care physician did 
not refer these services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for lab work provided on February 27, 2020 by an out 
of network (OON) provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the services (CPT 87633) provided on April 7, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that this is a non-
covered service. 
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan contends that the requested services are not covered according to LCA 
A54769. Review of the documentation submitted and the aforementioned article do not show that this is a non-
covered service. Without supporting documentation, the Plan?s denial cannot be substantiated. Therefore, we 
decided that the Plan has to pay for the services (CPT 87633) provided on April 7, 2020.  
 
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 Comprehensive Genomic Profile (CGP) testing provided to 
the enrollee on March 21, 2020. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says Comprehensive Genomic Profile (CGP) testing NEXT-Generation? requires use of CPT 81479, 
and the appropriate DEX Z identifier entered adjacent in the comment narrative field. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare 
rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay 
for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on March 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray rendered on February 17, 2020. 
 
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 separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 71045 and 74022. Code 71045 is a column II code with a 
modifier indicator of 1 when billed with column I code 74022. Code 71045 was not billed with an appropriate 
modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the chest 
x-ray rendered on February 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on January 
26, 2020. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the charges 
because you were admitted to the hospital. 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 a $250 
copayment for ambulance services.  
 
You have been asked to pay a $250 copayment for ambulance services. Ambulance services fall 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 ambulance services 
provided on January 26, 2020.