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

 
We decided that the Plan does not have to waive the copayment for the specialist office visit. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that this was a routine visit 
for a hearing test so you do not have a copayment. The Plan denied your request. The Plan says you were 
charged a specialist 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 $45 
copayment for specialist Physician/Practitioner services.  
 
You have been asked to pay a $45 copayment for the specialist office visit. The specialist office visit falls 
within the Physician/Practitioner 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 copayment 
for the specialist office visit.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services. 
 
You asked the Plan to pay for the laboratory 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 
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 laboratory services.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for a continuous positive airway pressure (CPAP) device. 
 
You asked the Plan to pay for a CPAP device. You say that this was submitted with the correct identification 
number. The Plan denied your request. The Plan says that the claim form was missing the tax identification 
number. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan states that the claim form is missing required information; however, the 
Plan has not submitted the claim form. Without this documentation, the denial for missing information cannot 
be verified. Therefore, we decided that the Plan has to pay for a continuous positive airway pressure (CPAP) 
device.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services provided March 
17, 2020 to March 20, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that the copayment 
should be waived. The Plan denied your request. The Plan says the correct amount 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). Your contract with the Plan clearly says that you must pay a $375 
copayment for days 1-5 for inpatient care.  
 
You have been asked to pay a $1,125 copayment for 3 days of inpatient hospital services. 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 inpatient hospital services provided March 17, 2020 to March 20, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on March 23, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the medical 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 received were neither emergent 
nor urgent and prior authorization was not obtained to seek out-of-network 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 the medical services provided on March 23, 2020 
by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services billed 
with CPT code 15004-58. 
 
You asked the Plan to pay for the surgical services. You say that this claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says the services described by code 15004 are not supported. 
 
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 15004 is Surgical preparation or creation of recipient site 
by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar 
contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 
sq cm or 1% of body area of infants and children. 
 
We asked our coding 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 surgical services. Our reviewer says that 
the billed code is not supported in the provided medical records. Our coding reviewer found documentation 
submitted was reviewed.  Per CPT guidelines, it is not appropriate to report 15002-15005 for removal of 
nonviable tissue/debris in a chronic wound (eg venous or diabetic) when the wound is left to heal by secondary 
intentions. 
 
We looked at this coder?s review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the surgical services have not been met. Therefore, we decided that the Plan 
does not have to pay for the surgical services provided CPT code 15004-58.
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 
December 2, 2019 to December 5, 2019. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. You say that you feel you should not 
be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan 
denied your request. The Plan says you received inpatient hospital care on the dates of service at issue in this 
appeal. The Plan says that the correct copayment has applied per your contract with the Plan. 
 
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 $345 
copayment each day for days 1-5 for Inpatient hospital care.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received inpatient 
hospital care from December 2, 2019 to December 5, 2019. You have been asked to pay a $345 copayment 
each day for days 1-3 for the inpatient hospital care, totaling $1035. The inpatient hospital care falls within the 
Inpatient hospital 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 inpatient 
hospital care provided from December 2, 2019 to December 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical nutrition therapy services provided. 
 
You asked the Plan to pay for medical nutrition therapy services. You say that this is medically necessary. The 
Plan denied your request. The Plan says medical nutrition therapy (MNT) is covered by Medicare only for 
diabetes and renal disease. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the 
Plan does not have to pay for medical nutrition therapy services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on May 9, 2020. 
 
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 there is no evidence of a hands-on physical exam to make medical determinations. 
 
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 services. Our reviewer says that the 
services at issue in this case were not medically reasonable or necessary. Our physician reviewer found there 
are no clinical records in the case file supporting that a Full Hereditary Cancer panel (32 genes) by myTest 
Diagnostics was medically reasonable and necessary for the enrollee in this case. The medical records are 
limited to the Cancer Genetics Requisition Form and the results of Cancer Detect Extended testing. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for laboratory services provided to the enrollee on May 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the services rendered from February 20, 
2020 to March 5, 2020. 
 
You asked the Plan to waive the copayments for these services. You say that you should not have an ER 
copayment because the doctor told you to go and you should only have $10 copayments for the therapy visits. 
The Plan denied your request. The Plan says the copayments were 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 $10 
copayment for group and individual therapy visits, an $80 copayment for each ER visit, and a $20 copayment 
for in-network specialty care physician services. 
 
Review of the file shows that you received outpatient mental health services on February 20, 2020. You have 
been asked to pay a $10 copayment for these services. These services fall within the group and individual 
therapy visits benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan.  
 
The file shows that you received ER services on February 29, 2020. You have been asked to pay an $80 
copayment for these services. These services fall within the ER visit in the US benefit category. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. 
 
The file shows that you received specialty services from a psychiatrist on March 5, 2020. You have been asked 
to pay a $20 copayment for these services. These services fall within the specialty care physician services 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. 
 
The total amount you have been asked to pay for these services is $110. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayments for the services rendered from February 20, 2020 to March 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special pump services (CPT code 99190) provided on 
February 21, 2020. 
 
You asked the Plan to pay for CPT code 99190. 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 does not pay any provider or supplier other than the facility or 
hospital for services furnished to the beneficiary while an inpatient.  
 
We looked at the file and Medicare rules. In this case, the file shows the enrollee received these services during 
an inpatient hospitalization. Payment for these services were included in the facility payment. Therefore, we 
decided that the Plan does not have to pay for the special pump services (CPT code 99190) provided on 
February 21, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Comprehensive Genomic Profile (CGP) testing. 
 
You asked the Plan to pay for the Comprehensive Genomic Profile (CGP) testing. 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 Comprehensive Genomic Profile (CGP) testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the Comprehensive Genomic Profile (CGP) testing.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transitional care management services (CPT 99496) provided 
to the enrollee. 
 
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 this was denied for coding irregularities. 
 
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 99496 is "Transitional Care Management Services." 
 
We asked our coding 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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our coding reviewer found the medical 
records provided do not validate that either the definition of 99496 and place of service 11 are supported on 
, therefore this service cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. 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 transitional care management services (CPT 99496) provided to the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from March 5, 
2020 to March 16, 2020. 
 
You asked the Plan to pay for SNF care. You say that this should be covered by Medicare. The Plan denied 
your request. The Plan says these services were custodial. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for SNF care. Our reviewer says that daily 
skilled services were not necessary. Our physician reviewer found the enrollee did not require skilled nursing 
services or skilled therapy services. The documentation does not support the need for therapy services on a 
daily basis. The enrollee did not make any changes in her mobility or activities of daily living for months. The 
enrollee's care needs were custodial. 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from March 5, 2020 to March 16, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve the Caris MI Profile genetic testing. 
 
You asked the Plan to pre-approve the Caris MI Profile genetic testing. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says that the services rendered are not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Caris MI Profile genetic testing is 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 the Caris MI Profile genetic testing. 
Our reviewer says that the documentation does support that the rendered services are medically reasonable and 
necessary. Our physician reviewer found the enrollee has a diagnosis of Malignant neoplasm of overlapping 
sites of bladder. The enrollee has Stage IVB invasive papillary urothelial carcinoma which is metastatic, 
involving the liver, lungs, and bones. The enrollee has undergone trans-urethral resection of bladder tumor 
(TURBT). A nephrostomy tube has been placed in the right kidney. The enrollee has received systemic 
chemotherapy. The documentation supports that the enrollee had a diagnosis, condition, and/or symptoms that 
meet the Medicare criteria for coverage the services rendered. The test results have the potential to provide the 
clinician with information that will improve the outcome and/or change physician care and treatment of the 
enrollee in this case. NCCN states that the panel recommends that molecular/genomic testing be performed for 
stages IVA and IV B bladder cancer. The NCCN Bladder Cancer Panel recommends that molecular/genomic 
testing be carried out early, ideally at diagnosis of advanced bladder cancer, in order to facilitate treatment 
decision-making and to prevent delays in administering later lines of therapy. Therefore, the enrollee met 
criteria for the services rendered. 
 
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 Caris MI Profile genetic testing have been met. Therefore, we decided that 
the Plan has to pre-approve the Caris MI Profile genetic testing.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services coded 99291 and 99292 provided on 
April 17, 2020. 
 
You asked the Plan to pay for the critical care services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the documentation does 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 code 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
The CPT Code Manual definition of code 99292 is Critical care, evaluation and management of the critically ill 
or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service). 
 
We find that CPT codes 99291 and 99292 are not supported in the medical record. Specifically, the 
documentation submitted did not support a critical care visit of 30-74 minutes was performed on the billed date 
of service. The documentation does not include the time spent providing this service. In addition, the primary 
code (99291) is denied, therefore, the add-on codes of 99292 cannot be separately reimbursed. Based on this 
information, we decided that Medicare rules for coverage of the critical care services have not been met. 
Therefore, we decided that the Plan does not have to pay for the critical care services coded 99291 and 99292 
provided on April 17, 2020.