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

 
We decided that the Plan does not have to pay for chiropractic services (72081, 99241, 98941) provided March 
11, 2020 to April 28, 2020. 
 
You asked the Plan to pay for the chiropractic services. You say that the services should be covered. The Plan 
denied your request. The Plan says these chiropractic services are not a covered benefit. 
 
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 chiropractic services (72081, 99241, 98941) provided March 11, 2020 to 
April 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis, bitewings, and periodic oral evaluation 
provided on June 19, 2020 by an OON provider. 
 
You asked the Plan to pay for the prophylaxis, bitewings, and periodic oral evaluation. You say that you 
received routine preventive care, and your Plan states that you pay $0 copayments for preventive care, 
including out-of-network services. The Plan denied your request. The Plan says the total liability amount of 
$126.00 was applied correctly. The Plan also says that member liability is a contractual obligation under the 
Plan that cannot be waived. 
 
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 the difference 
between the billed amount and allowed amount. Therefore, we decided that the Plan does not have to pay for 
the prophylaxis, bitewings, and periodic oral evaluation provided on June 19, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foradhesive bandages (A6413) provided March 28, 2020 to April 7, 2020.You asked the Plan to pay forthe bandages. You say that the bandages should be covered.The Plan denied your request. The Plan says This type of bandage is non-covered. There was no qualifying wound.The Plan must follow Medicare rules. Medicare rules say that First-aid type adhesive bandages (A6413), and Small adhesive bandages (e.g., Band-Aid or similar product) are non-covered. We looked at the file and Medicare rules. The items at issue are not a covered benefit. Based on this information, we decided that Medicare rules for coverage of the bandages have not been met.Therefore, we decided that the Plan does not have to pay foradhesive bandages (A6413) provided March 28, 2020 to April 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth services (99214 and 90833) provided on May 29, 
2020. 
 
You asked the Plan to pay for the telehealth services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says these codes have been billed with an 
inappropriate modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that CPT codes 99214 and 90833 
 are not supported in the record. Specifically, per CMS it is inappropriate to bill these codes with the GT 
modifier. Based on this information, we decided that Medicare rules for coverage of the telehealth services 
have not been met. Therefore, we decided that the Plan does not have to pay for telehealth services (99214 and 
90833) provided on May 29, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services provided on May 18, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were billed incorrectly.The Plan must follow Medicare rules. Medicare rules say that certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the ICD10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, followed by the manifestation. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Specifically, the record shows that the claim was billed with primary diagnosis code, E08.65. This code has a code first note, which means it is a manifestation code and must be sequenced after an etiology code.Therefore, we decided that the Plan does not have to pay forthe services provided on May 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physician services provided by a 
participating provider on April 20, 2020. 
 
You asked the Plan to waive the copayment for physician services. You say that you did not see a doctor on 
that day. 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 $20 
copayment for physician/practitioner services/PCP remote evaluation.  
 
You have been asked to pay a $20 copayment for physician services. Since results were reviewed and a 
treatment plan was made, the correct copayment for physician services has been applied. Physician services fall 
within the physician/practitioner services/PCP remote evaluation 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 physician services provided by a participating provider on April 20, 2020.
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. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
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 24, 
2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit coded 99285 provided on 
January 15, 2020. 
 
You asked the Plan to pay for the emergency department visit. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the 
documentation. 
 
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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. Counseling and/or coordination of care with 
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature 
of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function. . 
 
We find that CPT code 99285 is not supported in the medical record. Specifically, the nature of the presenting 
problem was found to be moderate. Therefore, there is a better suited code for the services provided. Based on 
this information, we decided that Medicare rules for coverage of the emergency department visit have not been 
met. Therefore, we decided that the Plan does not have to pay for the emergency department visit coded 99285 
provided on January 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on January 22, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the psychotherapy services (90832) provided on January 22, 2020.. You say that 
you would like reconsideration because it is the responsibility of the facility to obtain prior authorization. The 
Plan denied your request. The Plan says utilization of network providers is required when possible and 
available. 
 
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 22, 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 laboratory services provided on April 29, 2020 by an out 
of network (OON) provider. 
 
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 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 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 laboratory services provided on April 29, 2020 
by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on March 4, 
2020. 
 
You asked the Plan to pay for the limited oral evaluation (D0140). You say that your dentist referred you to 
another DMD to evaluate whether the tooth could be successfully treated. You say that you expect insurance to 
cover this expense. The Plan denied your request. The Plan says procedure code D0140 is covered once per 
plan year. 
 
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 also have a maximum benefit of 
one limited oral evaluation per plan year. The Plan paid for a limited oral evaluation provided on February 12, 
2020, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the limited 
oral evaluation (D0140) provided on March 4, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on March 28, 2020. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
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 28, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for arthrocentesis provided on July 21, 2020. 
 
You asked the Plan to waive the copayment for arthrocentesis. You say that the charges are too high for an 
injection into your hip. 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 $450 
copayment for outpatient surgery, including services provided at hospital outpatient facilities.  
 
You received arthrocentesis on July 21, 2020. Arthrocentesis is considered an outpatient surgical procedure. 
Therefore, you are responsible to pay the allowed amount of $271.74, which is less than the $450 copayment.  
 
You have been asked to pay $271.74 for arthrocentesis. Arthrocentesis falls within the outpatient surgery, 
including services provided at hospital outpatient facilities and ambulatory surgical centers 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 arthrocentesis provided on July 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided from February 5, 
2020, through February 17, 2020. 
 
You asked the Plan to pay for the subsequent nursing facility care. 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 subsequent nursing facility care provided from February 5, 2020, 
through February 17, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health/hospice aide services in home health or hospice 
settings, each 15 minutes (G0156) direct skilled nursing services in the home health or hospice setting, each 15 
minutes (G0299) provided December 2, 2019 to December 31, 2019. 
 
You asked the Plan to pay for the home health services. You say that the enrollee has in network and out of 
network benefits and the account should be paid in full. The Plan denied your request. The Plan says treatment 
authorization code missing/invalid 
 
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, claims are required to have the treatment authorization code, Q code, HHRG code and correct bill 
type to process for payment. The claim was submitted with no "Q" codes and no treatment authorization code. 
Based on this information, we decided that Medicare rules for coverage of the home health services have not 
been met. Therefore, we decided that the Plan does not have to pay for home health/hospice aide services in 
home health or hospice settings, each 15 minutes (G0156) direct skilled nursing services in the home health or 
hospice setting, each 15 minutes (G0299) provided December 2, 2019 to December 31, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from 
March 4, 2020, through March 14, 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 services 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 $250 
copayment per day, for days 1-7 and a $0 copayment per day, for days 8-90, for inpatient hospital care. 
 
You have been asked to pay $1,750 ($250 copayment x 7 days) for the inpatient hospital care provided. 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 inpatient hospital care provided from March 4, 2020, 
through March 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forcomprehensive genomic profile (CGP) testing provided on March 30, 2020.You asked the Plan to pay forgenetic testing. You say that the enrollee's treating physician ordered this testing to determine if there was a more effective therapy for the enrollee's condition.The Plan deniedyour request. The Plan says the denial of payment for this testing is correct, because this testing was not billed with the appropriate coding.The Plan must follow Medicare rules. Medicare rules say that CGP testing must be billed with CPT code 81479 for date of service March 30, 2020. We looked at the file and Medicare rules. This testing was not billed with the appropriate coding. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met.Therefore, we decided that the Plan does not have to pay forcomprehensive genomic profile (CGP) testing provided on March 30, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a finger x-ray (73140) provided on March 31, 2020. 
 
You asked the Plan to pay for the finger x-ray. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says it is not appropriate to report unspecified, left, 
right or bilateral diagnosis codes when the procedure modifier on the claim line does not match the diagnosis 
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. 
 
We find that CPT code 73140 is not supported in the record. Specifically, the record does not include a 
modifier to indicate the laterality of the procedure rendered. Based on this information, we decided that 
Medicare rules for coverage of the finger x-ray have not been met. Therefore, we decided that the Plan does not 
have to pay for a finger x-ray (73140) provided on March 31, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on March 17, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code cannot 
be verified. 
 
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 March 17, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided on 
March 24, 2020. 
 
You asked the Plan to pay for genetic testing. You say that the enrollee's treating physician ordered this testing 
to determine if there was a more effective therapy to treat the enrollee's condition. The Plan denied your 
request. The Plan says the denial of payment for this testing is correct, because this testing was not billed with 
the appropriate coding. 
 
The Plan must follow Medicare rules. Medicare rules say that CGP testing must be billed with CPT code 81479 
for date of service March 24, 2020.  
 
We looked at the file and Medicare rules. This testing was not billed with the appropriate coding. Based on this 
information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we 
decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided on 
March 24, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided on 
March 21, 2020. 
 
You asked the Plan to pay for genetic testing. You say that the enrollee's treating physician ordered this testing 
to determine if there was a more effective therapy to treat the enrollee's condition. The Plan denied your 
request. The Plan says the denial of payment for this testing is correct, because this testing was not billed with 
the appropriate coding. 
 
The Plan must follow Medicare rules. Medicare rules say that CGP testing must be billed with CPT code 81479 
for date of service March 21, 2020.  
 
We looked at the file and Medicare rules. This testing was not billed with the appropriate coding. Based on this 
information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we 
decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided on 
March 21, 2020.