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

 
We decided that the Plan does not have to waive the copayments for specialist visits provided on June 27, 2020 
and June 28, 2020. 
 
You asked the Plan to waive the copayments for specialist visits. You say that you disagree with the charges 
because you were in 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 $35 
copayment for each specialist visit. 
 
The medical records show that you received specialist visits on June 27, 2020 and June 28, 2020 during an 
observation stay. Therefore, you are responsible to pay a $35 copayment per each visit. The total amount you 
owe is: $70.   
 
You have been asked to pay the total copayment amount of $70 for specialist visits. Specialist visits fall within 
the outpatient hospital 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 copayments for 
specialist visits provided on June 27, 2020 and June 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stocking identified with code A6549 that 
were issued on April 11, 2020. 
 
You asked the Plan to pay for the compression stocking. You say that this was the only supplier you could find 
to provide this item. The Plan denied your request. The Plan says the denial of payment for this item is correct, 
because this provider is not enrolled in the Medicare program and is not payable. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing. The rules also say that a 
supplier must be enrolled in the Medicare program to receive payment. Although this item may be appropriate, 
it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Furthermore, 
this provider is not enrolled in the Medicare program and is not payable by the Plan. Therefore, we decided that 
the Plan does not have to pay for the compression stocking identified with code A6549 that were issued on 
April 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ophthalmology exam and imaging 
provided on June 22, 2020. 
 
You asked the Plan to waive the copayment for the ophthalmology exam and imaging. You say that this was a 
routine eye exam so there should not be a copayment. The Plan denied your request. The Plan says you have 
been charged this copayment 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 Medicare covered exams to diagnose and treat diseases of the eye.  
 
You have been asked to pay a $40 copayment for the ophthalmology exam and imaging. The ophthalmology 
exam and imaging falls within the Vision 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 
copayment for the ophthalmology exam and imaging provided on June 22, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for chest X-rays (71046) performed on May 5, 
2020. 
 
You asked the Plan to waive the copayment for chest X-rays. You say that chest X-rays should be covered as 
part of the enrollee's surgery. The Plan denied your request. The Plan says the correct copayment was 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). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $40 copayment for each basic imaging service (e.g. general X-rays or ultrasound).  
 
The enrollee has been asked to pay a $40 copayment for chest X-rays. Chest X-rays fall within the "Outpatient 
diagnostic tests and therapeutic services and supplies" 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 waive the copayment for chest X-rays (71046) performed on May 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for unlisted molecular pathology procedure (81479) provided 
May 4, 2020. 
 
You asked the Plan to pay for unlisted molecular pathology procedure. You say that you are appealing the 
decision that this test is experimental/investigational and request that this is processed in network since you are 
the only service provider for this service. The Plan denied your request. The Plan says there is a more 
appropriate code to describe the services provided. Providers must not unbundle the services described by a 
HCPCS/CPT code. 
 
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 81479 is unlisted molecular pathology procedure. 
 
We find that CPT code 81479 is not supported in the medical record. Specifically, Medicare requires use of 
CPT 81479 to report a Guardant360 molecular pathology genomic profiling for breast cancer, and the 
appropriate DEX Z-Code identifier must be entered adjacent to the CPT code 81479 in the comment/narrative 
field. Based on this information, we decided that Medicare rules for coverage of unlisted molecular pathology 
procedure have not been met. Therefore, we decided that the Plan does not have to pay for unlisted molecular 
pathology procedure (81479) provided May 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first 15 minutes of deep sedation/general anesthesia 
provided on May 6, 2020. 
 
You asked the Plan to pay for the deep sedation/general anesthesia. You say that you received a letter that 
showed the service would be partially covered, and you feel the letter is contradictory. The Plan denied your 
request. The Plan says this service is not a covered 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 first 
15 minutes of deep sedation/general anesthesia provided on May 6, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 8, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
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 laboratory services have not been met. Therefore, we decided that the Plan does not 
have to pay for the laboratory services provided on April 8, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 31, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
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, Medicare guidelines say when billing for the Guardant360 molecular lab panel, procedure code 
81479 is the only code available for billing. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay 
for the laboratory services provided on March 31, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 7, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
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 laboratory services have not been met. Therefore, we decided that the Plan does not 
have to pay for the laboratory services provided on May 7, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 30, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
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, Medicare guidelines say when billing for the Guardant360 molecular lab panel, procedure code 
81479 is the only code available for billing. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay 
for the laboratory services provided on April 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 testing provided on April 7, 2020. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like reconsideration because 
the testing services were medically necessary. The Plan denied your request. The Plan says there is a more 
appropriate code to describe the services provided. 
 
The Plan must follow Medicare rules. Medicare rules say that to report a CGP service, test providers should use 
CPT code 81479 at this time.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Guardant360 testing have not been met. Specifically, CPT code 81479 is the more appropriate 
code the describe the services that were provided. Therefore, we decided that the Plan does not have to pay for 
Guardant360 testing provided on April 7, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 9, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
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 laboratory services have not been met. Therefore, we decided that the Plan does not 
have to pay for the laboratory services provided on April 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the custom fabricated mandibular advancement oral 
appliance provided on February 25, 2020. 
 
You asked the Plan to pay for the oral appliance. You say that this is medically necessary. The Plan denied 
your request. The Plan says that the enrollee does not meet criteria for the oral airway appliance. 
 
The Plan must follow Medicare rules. Medicare rules say that a custom fabricated mandibular advancement 
oral appliance must be provided and billed for by a licensed dentist. 
 
 
We looked at the file and Medicare rules. The file indicates that the custom fabricated mandibular advancement 
oral appliance was not provided and billed for by a licensed dentist. Based on this information, we decided that 
Medicare rules for coverage of the oral appliance have not been met. Therefore, we decided that the Plan does 
not have to pay for the custom fabricated mandibular advancement oral appliance provided on February 25, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar sacral orthosis provided to the enrollee on March 
5, 2020. 
 
You asked the Plan to pay for the orthosis. You say that this item was medically necessary. The Plan denied 
your request. The Plan says that the submitted office visit notes do not indicate anything regarding an order or 
any type of need for a Mobility Back Brace. 
 
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 orthosis. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. An appropriate 
history and a physical examination of the back would reasonably be required to adequately assess whether the 
coverage criteria for an LSO have been met. The documentation does not support that the lumbar-sacral 
orthosis was prescribed for one or more of the covered indications in this case, as there is no documentation of 
a credible physical examination of the back. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for the orthosis. 
 
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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pay for the lumbar sacral orthosis provided to the enrollee on March 5, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by you on April 19, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 19, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided by you on April 
19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on March 9, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. 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 physician's services provided on March 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Imfinzi (durvalumab) injections 
provided from April 1, 2020 to May 27, 2020. 
 
You asked the Plan to waive the coinsurance for the Imfinzi (durvalumab) injections (J9173). You say that you 
need the injections but you cannot afford the coinsurance. The Plan denied your request. The Plan says you 
were charged the coinsurance 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 20% 
coinsurance for Medicare Part B covered prescription drugs.  
 
You have been asked to pay a 20% coinsurance for the durvalumab injections (J9173). The durvalumab 
injections (J9173) 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 Imfinzi (durvalumab) injections provided from April 1, 2020 to 
May 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the intraoral complete series x-ray provided on 
February 25, 2020. 
 
You asked the Plan to pay more for the intraoral complete series x-ray. You say that you were informed the 
cost of the initial, dental examination and x-rays would be fully covered. You say that you weren't informed the 
x-ray would result in a significant additional charge. The Plan denied your request. The Plan says the claim 
processed correctly. 
 
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 responsible for 50% of the 
allowed amount for intraoral x-rays. The allowed amount is $110 ($110 x 50% = $55). Therefore, we decided 
that the Plan does not have to pay more for the intraoral complete series x-ray provided on February 25, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on February 10, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says that the Plan 
requires utilization of network providers when possible and available, and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented. 
 
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 did not pre-approve the 
laboratory services. 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 laboratory services provided on February 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for unlisted molecular pathology procedure (81479) provided 
May 7, 2020. 
 
You asked the Plan to pay for unlisted molecular pathology procedure. You say that you are appealing the 
decision that the test is experimental/investigational and request processing of the claim in-network since you 
are the only servicing provider for this test. The Plan denied your request. The Plan says here is a more 
appropriate code to describe the services provided. Procedures shall be reported with the most comprehensive 
CPT code that describes the services performed. Providers must not unbundle the services described by a 
HCPCS/CPT code. 
 
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 81479 is unlisted molecular pathology procedure. 
 
We find that CPT code 81479 is not supported in the medical record. Specifically, Medicare requires use of 
CPT 81479 to report a Guardant360 molecular pathology genomic profiling for NSCLC, and the appropriate 
DEX Z-Code identifier must be entered adjacent to the CPT code 81479 in the comment/narrative field. Based 
on this information, we decided that Medicare rules for coverage of unlisted molecular pathology procedure 
have not been met. Therefore, we decided that the Plan does not have to pay for unlisted molecular pathology 
procedure (81479) provided May 7, 2020.