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

 
We decided that the Plan does not have to pay for the medical services provided on September 25, 2019 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that these services were provided in good faith and 
were medically necessary. The Plan denied your request. The Plan says unauthorized, non-plan care is not 
covered. 
 
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 September 25, 
2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on October 21, 2019. 
 
You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services billed must be submitted to the enrollee's primary 
insurer. 
 
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 met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the 
provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible 
for the office visit until the primary insurer has denied the claim for these services. Therefore, we decided that 
the Plan does not have to pay for the office visit provided on October 21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthoses provided on January 23, 2020. 
 
You asked the Plan to pay for the knee orthoses (L1833). You say that the orthoses were medically necessary. 
The Plan denied your request. The Plan says the documentation submitted did not indicate the need for the 
billed supply code, therefore the billed supply code cannot be verified. 
 
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 or relevant medical records which support medical 
necessity for the supplies provided in this case. The physician order is for suspension sleeves. There are no 
medical records, around the date of the order, supporting medical necessity for the orthosis.  
 
 
 
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 the knee orthoses on January 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 molecular pathology provided on April 1, 
2020. 
 
You asked the Plan to pay for the Guardant360 pathology. You say that you would like reconsideration because 
all of the member's available treatment options require molecular testing to determine eligibility. The Plan 
denied your request. The Plan says Medicare requires the use of CPT code 81479 to report a Guardant360 
molecular pathology genomic profiling for NSCLC and an appropriate DEX Z-Code. 
 
The Plan must follow Medicare rules. Medicare rules say that  providers must report services correctly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Guardant360 pathology have not been met. Specifically, per Medicare guidelines, the more 
appropriate CPT code for this pathology is 81479. Additionally, this claim was not submitted with an 
appropriate DEX Z-Code. Therefore, we decided that the Plan does not have to pay for Guardant360 molecular 
pathology provided on April 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on February 4, 2020. 
 
You asked the Plan to pay for the laboratory 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 
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 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Bevacizumab injection provided on 
January 30, 2020. 
 
You asked the Plan to waive the coinsurance for the Bevacizumab injection (J9035). You say that the shots are 
covered 100%. 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 prescription drugs.  
 
You have been asked to pay a 20% coinsurance for the Bevacizumab injection (J9035). The Bevacizumab 
injection (J9035) falls 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 Bevacizumab injection provided on January 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0651).
You asked the Plan to pay for a pneumatic compression device. You say that the enrollee requires the device. The Plan denied your request. The Plan says four-week trial of conservative therapy demonstrating failed response to treatment is required.
The Plan follows Medicare rules. The rules state that a PCD coded as E0651 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response including se of an appropriate compression bandage system or compression garment, exercise, and elevation of the limb.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular conservative therapy that is documented by your doctor. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0651).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on November 
5, 2019. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
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 the denied codes is: 
 
CPT 80157: 
 
Carbamazepine; free 
 
CPT 80159: 
 
Clozapine 
 
CPT 80162: 
 
Digoxin; total 
 
CPT 80173: 
 
Haloperidol 
 
CPT 80177: 
 
Levetiracetam 
 
CPT 80201: 
 
Topiramate 
 
 
 
We find that the denied codes are not supported in the medical record. Specifically, there is no valid physician 
order for these services, and the services were done by urine sampling rather than blood sampling. 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 drug testing services provided to the enrollee on November 5, 
2019.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on 
November 25, 2019. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you disagree with the 
charges. The Plan denied your request. The Plan says the copayment you are being charged is correct. 
 
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 $90 
copayment for each hospital emergency room visit.  
 
You have been asked to pay a $90 copayment for an emergency room visit. An emergency room visit falls 
within the emergency 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 an 
emergency room visit provided on November 25, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a stress test provided by a participating provider on March 24, 2020.
You asked the Plan to waive the copayment for a stress test. You say that you were told there would be no copayment. 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 $150 copayment for outpatient diagnostic tests/MRI,CT,PET. You have been asked to pay a $150 copayment for a stress test. The correct copayment has been applied to the service provided. A stress test falls within the outpatient diagnostic tests/MRI, CT, PET 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 a stress test provided by a participating provider on March 24, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab work provided on December 9, 2019 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for lab work. 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 lab work provided on December 9, 2019 by an out 
of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on February 1, 2020. 
 
You asked the Plan to pay for the ambulance services. 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 February 1, 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 on February 1, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a breast MRI. 
 
You asked the Plan to pre-approve a breast MRI. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that breast MRIs are only covered for certain indications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a breast MRI. Our reviewer says that 
the documentation does not support that the requested MRI is medically reasonable or necessary. Our physician 
reviewer found you have a past medical history of hyperlipidemia and a family history of breast cancer.  
 
You had a diagnostic mammogram and ultrasound on July 27, 2020 showing stable likely benign left breast 
nodularity and a 4 mm hypoechoic nodule. A follow-up mammogram and ultrasound in six months were 
recommended. The documentation does not support that you meet criteria for the requested breast MRI. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a breast MRI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a breast MRI.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on March 20, 2020. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 Guardant360 testing is not supported in the medical record. Specifically, this service should be 
billed with code 81479. In addition, the appropriate DEX Z code should be entered adjacent in the 
comment/narrative field. Based on this information, we decided that Medicare rules for coverage of the 
Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
Guardant360 testing provided on March 20, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to adjust the copayment, to $10, for the office visit provided on February 18, 
2020. 
 
You asked the Plan to adjust the copayment, to $10, for office or other outpatient visit for the evaluation and 
management of an established patient (99213). You say that your copayment should only be $10. The Plan 
denied your request. The Plan says that you were charged the $40 copayment correctly. 
 
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 enrollees must pay a $10 copayment for Physician/practitioner services, 
including doctor's office visits.  
 
The Plan says you must pay $40 copayment for office or other outpatient visit for the evaluation and 
management of an established patient (99213). Based on the Plan contract, however, you cannot be asked to 
pay more than a $10 copayment for office or other outpatient visit for the evaluation and management of an 
established patient (99213). The record supports that this was a primary care office visit with an immunization. 
The Plan has not successfully determined this was a specialist visit. Therefore, we decided that the Plan has to 
adjust the copayment, to $10, for the office visit provided on February 18, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the re-cement or re-bond crown provided on May 11, 2020.
You asked the Plan to pay for the re-cement or re-bond crown. You say that you never used your total dental benefit amount every year. You say that correcting this is more important than having teeth cleaned. The Plan denied your request. The Plan says the 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 re-cement or re-bond crown provided on May 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist telemedicine service provided by a participating provider on March 6, 2020 to April 22, 2020.
You asked the Plan to waive the copayment for specialist telemedicine service. You say that you never had a visit. You say that you just had a phone call with a nurse about your medication. The Plan denied your request. The Plan says the correct copayments have 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 $40 copayment for physician/practitioner services/specialist. You have been asked to pay $10.38 and $10.42 which is less than your copayment amount of $40 for each specialist telemedicine service. The total amount you are being asked to pay is $52.02 ($10.38 + $10.38 + $10.42 + $10.42 + $10.42 = 52.02). Specialist telemedicine service falls within the physician/practitioner services/specialist 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 specialist telemedicine service provided by a participating provider on March 6, 2020 to April 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the end-stage renal disease (ESRD) services (90960) 
provided on December 31, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for OON ESRD services. You say that the facility should have obtained 
authorization for these medically necessary services. The Plan denied your request. The Plan says these 
services were not authorized. 
 
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 end-stage renal disease (ESRD) services 
(90960) provided on December 31, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Magnetic resonance (eg, proton) imaging, pelvis; without 
contrast material(s), followed by contrast material(s) and further sequences provided on November 6, 2019. 
 
You asked the Plan to pay for the Magnetic Resonance Imaging. You say that the Plan should pay this claim. 
The Plan denied your request. The Plan says the documentation submitted did not support the billed service. 
 
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 72197 is not supported in the medical record. Specifically, the medical records do not 
indicate that Magnetic resonance (eg, proton) imaging, pelvis; without contrast material(s), followed by 
contrast material(s) and further sequences was performed. Based on this information, we decided that Medicare 
rules for coverage of the MRI have not been met. Therefore, we decided that the Plan does not have to pay for 
Magnetic resonance (eg, proton) imaging, pelvis; without contrast material(s), followed by contrast material(s) 
and further sequences provided on November 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care services provided on 
February 16, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered 
benefit. 
 
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 subsequent nursing facility care services provided 
on February 16, 2020 by an out of network (OON) provider.