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

 
We decided that the Plan has to pay for the Guardant 360 genetic testing provided on May 11, 2020. 
 
You asked the Plan to pay for the Guardant 360 genetic testing. You say that the Guardant 360 genetic testing 
provided on May 11, 2020 was medically necessary. The Plan denied your request. The Plan says that the 
enrollee does not meet criteria for the provided Guardant 360 genetic testing provided on May 11, 2020. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 Guardant 360 genetic testing. Our 
reviewer says that the Guardant 360 genetic testing provided on May 11, 2020 was medically necessary. 
 Our physician reviewer found understanding the molecular drivers of cancer progression and metastases is an 
area of ongoing and active research, predominantly driven by the goal of identifying specific genomic 
aberrations that may ultimately result in individualized cancer treatment. In addition to likely providing 
prognostic information, the value of next generation sequencing (NGS) to predict candidates for specific 
mutation-driven treatment holds promise. Patients with inflammatory and metastatic breast cancers benefit 
from NGS to identify markers that may indicate benefit from targeted treatment or clinical trials, including 
PIK3CA mutations for the use of abemaciclib. This enrollee with an ER+ HER2 negative breast meets these 
criteria. The service was reasonable and medically necessary. 
 
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 Guardant 360 genetic testing have been met. Therefore, we decided that the 
Plan has to pay for the Guardant 360 genetic testing provided on May 11, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded G0482 provided on June 12, 2020. 
 
You asked the Plan to pay for the drug testing. 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 G0482 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 
drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0482 is not supported in the medical record. Specifically, the place of service on the 
CMS 1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The 
submitted claim form indicates the laboratory specimen was obtained in a laboratory; place of service 81, 
however, the submitted medical documentation and/or claim history indicates that the specimen was obtained 
in the office setting; place of service 11. Based on this information, we decided that Medicare rules for 
coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for 
the drug testing coded G0482 provided on June 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for frames (V2020), bifocal lens (V2203), polycarbonate lens 
(V2784) and vision services (V2799) provided on August 3, 2020. 
 
You asked the Plan to pay for frames, bifocal lens, polycarbonate lens and vision services. You say that the 
services should be covered. The Plan denied your request. The Plan says you are allowed $100 towards the 
purchase of eyewear every two years. 
 
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. The plan will cover $100 
towards eyewear every two years. 
 
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. Specifically, the Plan paid $100 toward the purchase of you eye wear, 
you are responsible for any amount over the $100 allowance. Therefore, we decided that the Plan does not have 
to pay for frames (V2020), bifocal lens (V2203), polycarbonate lens (V2784) and vision services (V2799) 
provided on August 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on July 
29, 2020. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that this was a follow-up 
appointment and you should not be responsible for a copayment. 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 $45 
copayment for services obtained from an in-network specialist. Or, under certain circumstances, by a nurse 
practitioner or physician's assistant or other non-physician health care professionals.  
 
You have 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. Please note, there 
is no provision in the contract which indicates a copayment would be waived if performed as a follow-up to a 
procedure. 
 
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 specialist office visit provided on July 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that the requested CGM is medically necessary. The 
Plan denied your request. The Plan says the clinical information does not indicate that the enrollee checks the 
glucose level four or more times per day and does not indicate the enrollee is on insulin injections three or 
more times per day. The Plan says that, because the coverage criteria have not been met, the requested CGM 
cannot be approved as reasonable and necessary. 
 
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 pre-approve the CGM. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the records show the enrollee is not taking insulin or checking blood glucose levels four times a 
day. Our physician reviewer found that there is not sufficient information regarding why glucometer checks are 
not sufficient and why the enrollee needs a CGM. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a Dexcom G6 continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on July 23, 2020. 
 
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says 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 
psychotherapy 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 psychotherapy services provided on July 23, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasounds provided on August 10, 2020. 
 
You asked the Plan to waive the copayment for the ultrasounds. You say that you cannot afford this. The Plan 
denied your request. The Plan says the copayments applied 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 $25 
copayment for carotid or peripheral vascular ultrasound.  
 
You have been asked to pay a $25 copayment for each ultrasound. The total amount you owe is $75 
($25/ultrasound x 3 ultrasounds = $75). The ultrasounds fall within the "Outpatient diagnostic tests and 
therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
the ultrasounds provided on August 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hearing aid (V5298) provided on August 11, 2020. 
 
You asked the Plan to pay for a hearing aid. You say that the service should be covered. The Plan denied your 
request. The Plan says there is no coverage if hearing aids or related services are received from a provider not 
part of the plans hearing aid vendors network. The hearing benefit is not covered if the services are not 
registered in advanced. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan?s coverage rules apply in this case. The Plan pays for 
hearing aids only when you contact the Plan's hearing services to register in advance of purchase.  
 
We looked at, the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aid have not been met. Specifically, you went outside the Plan?s hearing aid vendor?s 
network and did not call the Plan in advance to register. This means the hearing aid is not covered. Therefore, 
we decided that the Plan does not have to pay for a hearing aid (V5298) provided on August 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant surgery services provided on January 14, 2020. 
 
You asked the Plan to pay for the assistant services. The Plan denied your request. The Plan says an assistant at 
surgery is not payable. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered.  
 
In this case, you billed assistant surgery services for CPT code 22514. The Medicare Fee Schedule Database 
contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant 
surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare 
coverage criteria for the assistant services have not been met. Therefore, we decided that the Plan does not have 
to pay for the assistant surgery services provided on January 14, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic mammogram provided by a 
participating provider on August 26, 2020. 
 
You asked the Plan to waive the copayment for a diagnostic mammogram. You say that there shouldn't be a 
copayment for this. 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 outpatient diagnostic tests/x-rays and ultrasounds.  
 
You have been asked to pay a $20 copayment for a diagnostic mammogram. The mammogram that was 
provided was diagnostic in nature; therefore, the correct copayment has been applied. A diagnostic 
mammogram falls within the outpatient diagnostic tests/x-rays and ultrasounds 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 diagnostic mammogram provided by a participating provider on 
August 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional filling received on July 30, 2020. 
 
You asked the Plan to pay for the fillings. You say that this should be paid for. The Plan denied your request. 
The Plan says benefits for this service have been satisfied and exhausted. 
 
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. The Plan covers two dental 
fillings per year.  
 
The denied filling would be considered the third of the year. Based on this information, we decided that the 
Plan's rules for coverage of the fillings have not been met. Therefore, we decided that the Plan does not have to 
pay for an additional filling received on July 30, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing rendered on June 26, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the testing is not covered. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
genetic testing rendered on June 26, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for urine PCR panel testing provided on September 16, 2020. 
 
You asked the Plan to pay for laboratory testing. You say that the benefit of this testing over traditional culture 
is that the results are available within 24 hours as opposed to 3 or 4 days. The Plan denied your request. The 
Plan says the denial of payment for this testing is correct, because this testing is considered unproven, not 
medically necessary, not the standard of care, and the records do not show why this testing was ordered. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific 
lab services is required for covered lab services.  
 
We looked at the file and Medicare rules. The documentation submitted does not include a physician order or 
notes showing why this testing was ordered. Based on this information, we decided that Medicare rules for 
coverage of laboratory testing have not been met. Therefore, we decided that the Plan does not have to pay for 
urine PCR panel testing provided on September 16, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee x-ray (73562) provided August 19, 2020 
 
You asked the Plan to pay for the x-ray. You say that please review enclosed documentation. It is likely date of 
service was denied for same date of service with multiple physicians all with different specialties. The Plan 
denied your request. The Plan says this service is considered to be part of another service reported on this 
claim. Separate payment cannot be made for knee x-ray when billed in conjunction with a diagnostic vascular 
procedure. 
 
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, we have confirmed that code the x-
ray has a bundled relationship with code 93971 and cannot be paid as billed. This code cannot be paid as a 
separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the knee x-ray (73562) provided August 19, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional 8 simple extractions (D7140) and 4 surgical 
extractions (D7210) provided on July 29, 2020. 
 
You asked the Plan to pay for the dental services. You say that the provider wanted to charge you $1,900 more 
than what was quoted and agreed upon at the time of signing. The Plan denied your request. The Plan says 
there is an annual maximum benefit of $2,000 for covered dental services. The Plan says that the annual 
maximum benefit has been exhausted. The Plan also says that after the annual maximum is exhausted, any 
remaining charges are your responsibility. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the maximum benefit of $2,000 for 
covered dental services has been exhausted. The Evidence of Coverage clearly states that after the annual 
maximum is exhausted, any remaining charges are your responsibility. The record shows that the Plan paid 
$116 for services that you received on July 20, 2020 and $1,884 for services that you received on July 29, 
2020, thus exhausting the maximum benefit. Therefore, we decided that the Plan does not have to pay for the 
additional 8 simple extractions (D7140) and 4 surgical extractions (D7210) provided on July 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth services provided on June 15, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for telehealth services. You say that you would like this claim reprocessed and paid. 
The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that there are 
in-network physicians available to provide this care. 
 
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 telehealth services provided on June 15, 2020 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 medical services provided on May 21, 2020 by a non-
network 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 a non-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 medical services provided on May 21, 2020 by 
a non-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided by a chiropractor from July 8, 2020, to 
August 3, 2020. 
 
You asked the Plan to pay for the services provided. You say that the treatment should be covered. The Plan 
denied your request. The Plan says the services are 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 file shows that manual manipulation was provided. However, there are insufficient records provided to 
show that the services were medically necessary. Based on this information, we decided that the Medicare rules 
for coverage have not been met.  
 
The file shows that an office visit, electrical stimulation, and mechanical traction were provided. The records 
show that these services are not manual manipulation of the spine. Excluded from Medicare coverage is any 
service other than manual manipulation for the treatment of subluxation of the spine. Therefore, we decided 
that the Plan does not have to pay for the services provided by a chiropractor from July 8, 2020, to August 3, 
2020.