Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for portable X-Ray examination services provided on February 26, 2020. 
 
You asked the Plan to pay for portable X-Ray. You say that these services do not require prior authorization. 
The Plan denied your request. The Plan says that the denial of payment for these services 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. The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary 
insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying 
for services until the claim for those services has gone to the primary insurer. However, plans are still required 
to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary 
insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the 
Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and 
submit a bill for reimbursement to the primary insurer. 
 
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 provide a specific final decision rationale for their denial. 
However, among the submitted documentation is one remittance advice denying payment of the basis that prior 
authorization was not obtained, and another on the basis that the Plan is the secondary payer and the claim must 
be processed by the primary payer first. Neither of these denial reasons has been supported by the Plan. The 
Evidence of Coverage (EOC) does not clearly state that prior authorization is mandatory for portable X-Ray 
services, nor has any information been provided about the referral made for these services. Furthermore, the 
Plan has not submitted any evidence to support that this Plan is the secondary payer for the enrollee on this date 
of service, such as identifying the primary insurance payer. The Plan has also not provided any evidence that 
they have fulfilled the requirement to coordinate benefits with the primary insurance carrier. Without this 
information, the Plan has not shown that its decision to deny payment for these services is correct or justified 
by Medicare rules. Therefore, we decided that the Plan has to pay for portable X-Ray examination services 
provided on February 26, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit (99214) and an ultrasound
study (93922) provided on May 5, 2020.
You asked the Plan to waive the copayment for an office visit and an ultrasound study. You say that you should
not have two copayments. The Plan denied your request. The Plan says these services processed 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 $15
copayment for office visits and ultrasounds.
You have been asked to pay $15 copayments for an office visit and an ultrasound study. 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 an office visit (99214) and an ultrasound study (93922) provided on
May 5, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 Plasma-Based Comprehensive Genomic 
Profiling testing provided on March 17, 2020 billed with multiple line items of different CPT codes. 
 
You asked the Plan to pay for the Guardant 360 testing as billed. You say that this should not be denied as 
experimental as this is a proven test which is supported for this patient. The Plan denied your request. The Plan 
says on review, it was found that no payment can be made for this testing because the provider is unbundling 
when there is a single CPT code which describes this testing. 
 
The Plan must follow Medicare rules. Medicare rules say that in order to report the Guardant360 testing, one 
unit of code 81479 should be reported with the appropriate DEX Z-code.  
 
As there is a single CPT code which describes this testing, the rule for coverage of this testing as billed have 
not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 Plasma-Based 
Comprehensive Genomic Profiling testing provided on March 17, 2020 billed with multiple line items of 
different CPT codes.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Enteral formula, nutritionally complete, hydrolyzed 
proteins/amino acids (B4153) provided January 16, 2020. 
 
You asked the Plan to pay for the enteral formula. You say that please review the attached medical 
documentation and reprocess this claim accordingly. The Plan denied your request. The Plan says the records 
do not support the billed service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order, proof of delivery, or relevant medical records which 
support medical necessity for the supplies provided in this case. More specifically there submitted records does 
not include a physician's order for the billed date of service range and there is no itemized shipping/billing 
invoice and signed delivery sheet for billed service. The record shows that the Plan made several attempts to 
obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay 
for Enteral formula, nutritionally complete, hydrolyzed proteins/amino acids (B4153) provided January 16, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the specialist office visit provided on 
March 17, 2020. 
 
You asked the Plan to reduce the copayment for the specialist office visit. You say that the enrollee had a five 
minute conversation on the phone with the doctor and should not be charged the same as a face-to-face visit. 
The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $45 copayment per specialist visit.  
 
The enrollee has been asked to pay a $45 copayment for the specialist office visit. The specialist office visit 
falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. This means 
that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing 
is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the 
Plan does not have to reduce the copayment for the specialist office visit provided on March 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a 
participating provider on February 7, 2020. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you should not have to pay 
for the second surgery because it wasn't your fault. The Plan denied your request. The Plan says the correct 
copayment has been applied. 
 
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 outpatient surgery/in-network.  
 
You have been asked to pay a $250 copayment for an outpatient surgery. An outpatient surgery falls within the 
outpatient surgery/in-network 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 an 
outpatient surgery provided by a participating provider on February 7, 2020.  
 
We note your complaint about the second surgery not being your fault. Your complaint is a grievance that must 
be answered by the health plan. Medicare does not permit us to make a decision about these types of 
complaints.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on March 13, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
approved in advance. 
 
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 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 provided to the enrollee by an out-of-network provider 
on March 13, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the presumptive and definitive drug testing provided on July 
30, 2019. 
 
You asked the Plan to pay for the testing services. You say that the codes are supported by the physicians 
custom profile. The Plan denied your request. The Plan says the documentation did not include a valid 
physician order or medical records. 
 
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 drug testing at issue is not supported in the medical records. There is no evidence that shows the 
test was individualized to identify more specific non-prescribed medications or illicit substances. The records 
provided do not document concerns based on clinical review and judgement. Based on this information, we 
decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that 
the Plan does not have to pay for the presumptive and definitive drug testing provided on July 30, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on October 8, 2019. 
 
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 there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a 
physician. 
 
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 
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 drug testing rendered on October 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chiropractic office visit (99202) provided on March 26, 
2020. 
 
You asked the Plan to pay for a chiropractic office visit. You say that this relieved your pain. The Plan denied 
your request. The Plan says this is not covered. 
 
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 a chiropractic office visit (99202) provided on March 26, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the intraocular lens surgery (66986) 
provided on January 16, 2020. 
 
You asked the Plan to waive the copayment. 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 $450 
copayment for outpatient surgery provided at an in-network hospital facility.  
 
You have been asked to pay a $450 copayment for the outpatient surgery provided at the in-network hospital 
facility. 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 intraocular lens surgery (66986) provided 
on January 16, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyalgan. 
 
You asked the Plan to pre-approve Hyalgan. You say that your preferred product is Hyalgan. The Plan denied 
your request. The Plan says the information submitted does not meet the Plan's medical necessity guidelines for 
coverage. 
 
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 Hyalgan. Our reviewer says that 
Hyalgan does not meet coverage criteria. Our physician reviewer found based on the medical records provided, 
the enrollee has not tried and failed the required drug(s). Our reviewer also found that there is no indication that 
the Plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Hyalgan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hyalgan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine transportation trips provided from April 17, 2019 
to May 16, 2019. 
 
You asked the Plan to pay for the routine transportation trips. You say that you would like reimbursed for this 
trips. The Plan denied your request. The Plan says that you did not schedule any transportation. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers routine transportation when received from an in-network provider.  
 
We looked at your request, the records in the case file, and the rules. The file indicates you did not receive 
these services from an in-network provider. Based on this information, we decided that the Plan's rules for 
coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pay 
for the routine transportation trips provided from April 17, 2019 to May 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you more for the onlay (D2643) provided on January 17, 
2020. 
 
You asked the Plan to reimburse you more for the onlay (D2643). You say that you were overcharged. You say 
that you are requesting an $835 refund. The Plan denied your request. The Plan says a total refund of $685 is 
appropriate. 
 
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, you are only responsible for $540 for 
the onlay. The records show that you paid $825 for the onlay. This means that a refund of $285 for the onlay is 
appropriate ($825 - $540 = $285). Therefore, we decided that the Plan does not have to reimburse you more for 
the onlay (D2643) provided on January 17, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that the enrollee needs assistance with daily 
activities and having trouble with moving around their home due to amputation. The Plan denied your request. 
The Plan says that the enrollee is not shown to be able to complete skilled therapy 5 times a week, needing 
complex care that a nurse can't do in the home or receiving antibiotics through the veins. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 pre-approve SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for SNF services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on March 24, 2020. 
 
You asked the Plan to pay for the testing services. You say that providing an accurate somatic mutation profile 
is the best way to choose the optimal therapy for the enrollee. The Plan denied your request. The Plan says 
comprehensive genomic profile testing is not defined as a targeted panel. 
 
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 looked at the file and the rules. We find that the testing at issue has not been reported based on the coding 
and billing guidance. 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 Guardant360 testing provided on March 
24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home services and an drainage provided on May 30, 2019 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for home services and an outpatient surgery. 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. 
 
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 home services and an drainage provided on May 
30, 2019 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 testing services provided on October 8, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are 
not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab 
requisition stating exactly which testing was to be performed. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the drug testing services provided on October 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the mental health care visits provided on 
March 19, 2020 and April 2, 2020. 
 
You asked the Plan to waive the copayments for the mental health care visits. You say that you feel you should 
not have to pay a copayment for telemedicine visits. The Plan denied your request. The Plan says you have 
been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for each individual/group therapy visit. 
 
You have been asked to pay a $40 copayment for each of the mental health care visits. The mental health care 
visits fall within the "Outpatient mental health care" 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 
copayments for the mental health care visits provided on March 19, 2020 and April 2, 2020.