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

 
We decided that the Plan does not have to waive the copayment for an urgent care clinic visit (G0463) on 
February 12, 2020. 
 
You asked the Plan to waive the copayment for an urgent care clinic visit. You say that the copayment is 
incorrect. The Plan denied your request. The Plan says the correct copayment was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $50 copayment for urgently needed services received at an urgent care center.  
 
The enrollee has been asked to pay a $40.97 copayment for an urgent care clinic visit. An urgent care clinic 
visit falls within the "Urgently needed services" benefit category. This means that the enrollee has been asked 
to pay less than the full amount based on the contract with the Plan. This cost sharing is a contractual obligation 
the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to 
waive the copayment for an urgent care clinic visit (G0463) on February 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an X-ray provided on March 11, 2020. 
 
You asked the Plan to waive the copayment for an X-ray. You say that you feel that the X-ray should be 
included in the follow-up visit. 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 $40 
copayment for each x-ray.  
 
You had an X-ray provided on March 11, 2020. X-rays are not included in follow-up visits. Therefore, you are 
responsible to pay the $40 copayment.  
 
You have been asked to pay a $40 copayment for an X-ray. An X-ray falls 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 
an X-ray provided on March 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodontal procedure (D4999) provided on January 22, 
2020. 
 
You asked the Plan to pay for a periodontal procedure. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the dental services you received, the 
periodontal procedure with dental code D4999 is not covered by Medicare or the Plan's supplemental 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 a 
periodontal procedure (D4999) provided on January 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shingles vaccine rendered on March 3, 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 vaccine is not covered. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The 
Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to these services. 
Therefore, we decided that the Plan does not have to pay for the shingles vaccine rendered on March 3, 2020.  
 
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the re-cement or re-bond of a crown.
You asked the Plan to pay for the re-cement or re-bond of a crown.. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the services received are 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 recement
or re-bond of a crown.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ambulance services. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you were advised that 
there would be no charge for this ambulance. The Plan denied your request. The Plan says you were charged 
this cost sharing 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 $300 
copayment for each ambulance trip. You had one ambulance trip. The Plan charged you $282.03 for these 
services, which is less than your $300 copayment. 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 ambulance services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for knee x-rays (73562) provided on December 20, 2019. 
 
You asked the Plan to pay for the x-rays. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the documentation submitted does not support the 
service 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 73562 is radiologic examination, knee; 3 views.  
 
We find that CPT code 73562 is not supported in the medical record. Specifically, the documentation submitted 
does not support that x-rays with 3 views of the left knee were performed. Based on this information, we 
decided that Medicare rules for coverage of the x-rays have not been met. Therefore, we decided that the Plan 
does not have to pay for knee x-rays (73562) provided on December 20, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transportation provided on January 7, 2020. 
 
You asked the Plan to pay for ambulance transportation. You say that you are appealing with records. The Plan 
denied your request. The Plan says the denial of payment for this service is correct, because the enrollee could 
have been transported by other means such as gurney van. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance transportation. Our reviewer says 
that this ambulance transportation does not meet the Medicare criteria for payment. Our physician reviewer 
found based on the medical records provided there is no documentation that other means of transportation were 
contraindicated for the enrollee. There is no documentation that the enrollee needed the expertise, services, and 
life-saving and life-sustaining equipment that only a fully equipped ambulance can provide for safe 
transportation. The records do not show that this ambulance transportation was medically reasonable and 
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 ambulance transportation have not been met. Therefore, we decided that the 
Plan does not have to pay for ambulance transportation provided on January 7, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded G0483, 80157, 80177, 80201, 
80162, 80159 and 80173 provided on January 23, 2020. 
 
You asked the Plan to pay for the laboratory services. 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 payable. 
 
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 G0483, 80157, 80177, 80201, 80162, 80159 and 80173 is not supported in the medical 
record. Specifically, the documentation submitted did not include a physician order/lab requisition form or 
medical records stating exactly what tests were to be performed. Based on this information, we decided that 
Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory services coded G0483, 80157, 80177, 80201, 80162, 80159 and 80173 
provided on January 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on April 23, 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 identifier 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 April 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection services rendered on January 7, 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 procedure code 64492 is 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 64492 is injections of upper or middle spine facet joint 
using imaging guidance. 
 
We find that CPT code 64492 is not supported in the medical record. Specifically, there is no documentation of 
a diagnostic or therapeutic injection of the cervical or thoracic paravertebral facet joint with imaging guidance 
in the operative report. Based on this information, we decided that Medicare rules for coverage of these 
services have not been met. Therefore, we decided that the Plan does not have to pay for the injection services 
rendered on January 7, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory pathogen services coded 0100U provided on 
February 27, 2020. 
 
You asked the Plan to pay for the respiratory pathogen 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 payable. 
 
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 0100U is respiratory pathogen, multiplex reverse 
transcription and multiplex amplified probe technique, multiple types or subtypes, 21 targets (adenovirus, 
coronavirus 229E, coronavirus HKU1, coronavirus NL63, coronavirus OC43, human metapneumovirus, human 
rhinovirus/enterovirus, influenza A, including subtypes H1, H1-2009, and H3, influenza B, parainfluenza virus 
1, parainfluenza virus 2, parainfluenza virus 3, parainfluenza virus 4, respiratory syncytial virus, Bordetella 
parapertussis [IS1001], Bordetella pertussis [ptxP], Chlamydia pneumoniae, Mycoplasma pneumoniae). 
 
We find that CPT code 0100U is not supported in the medical record. Specifically, this service was provided 
while the enrollee was inpatient in the hospital. Payment for this service would be included in the Part A DRG 
payment to the facility. Based on this information, we decided that Medicare rules for coverage of the 
respiratory pathogen services have not been met. Therefore, we decided that the Plan does not have to pay for 
the respiratory pathogen services coded 0100U provided on February 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on May 28, 2019. 
 
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says 
that the Plan requires utilization of network providers when possible and available, and requires authorization 
for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency 
situation, has been documented.   
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
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 on May 28, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive genomic profile testing provided on April 4, 
2020. 
 
You asked the Plan to pay for genetic testing. You say that the treating physician ordered this testing to 
determine if there was a more effective treatment for 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 April 4, 2020.  
 
We looked at the file and Medicare rules. 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 testing provided on April 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for wound debridement provided from 
January 3, 2020 to January 31, 2020. 
 
You asked the Plan to waive the copayments for wound debridement. You say that you used to pay a $20 
copayment and cannot afford the charges. 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 $225 
copayment for outpatient surgery, including services provided at hospital outpatient facilities. 
 
You received wound debridement from January 3, 2020 to January 31, 2020 for a total of 3 services. Wound 
debridement is considered an outpatient surgical procedure. Therefore, you are responsible to pay a $225 
copayment per each service. The total amount you owe is: $225 (copayment) x 3 (wound debridement services) 
= $675.   
 
You have been asked to pay the total copayment amount of $675 for wound debridement. Wound debridement 
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 copayments for wound debridement 
provided from January 3, 2020 to January 31, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on January 27, 2020. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with records. The Plan denied your 
request. The Plan says the denial of payment for these services is correct, because the documentation submitted 
does not include a valid physician order, lab requisition, or medical records stating exactly which tests were to 
be performed and some of the lab tests billed do not match the specimen type for testing. 
 
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 valid physician 
order or clear intent to order the specific lab services billed on this claim. Based on this information, we 
decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan 
does not have to pay for laboratory testing provided on January 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cold pad with pump and shipping cost (E0218, 99199). 
 
You asked the Plan to pay for the cold pad and shipping fee. You say that the cold pad with pump was 
medically necessary. The Plan denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that a fluid circulating cold pad with pump (E0218) 
will be denied as not reasonable and necessary.  
 
We looked at the file and Medicare rules. The cold pad with pump is not eligible for Medicare coverage. Based 
on this information, we decided that Medicare rules for coverage of the cold pad and shipping fee have not 
been met. Therefore, we decided that the Plan does not have to pay for a cold pad with pump and shipping cost 
(E0218, 99199).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 and NEXT- generation testing provided on 
April 4, 2020. 
 
You asked the Plan to pay for the Guardant360 and NEXT- generation testing. 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 billed 
correctly. 
 
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 laboratory services billed are not supported in the medical record. Specifically, this service 
should be billed with code 81479. In addition, the appropriate DEX Z identifier should be entered adjacent in 
the comment/narrative field. Based on this information, we decided that Medicare rules for coverage of the 
Guardant360 and NEXT- generation testing have not been met. Therefore, we decided that the Plan does not 
have to pay for the Guardant360 and NEXT- generation testing provided on April 4, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services received on April 3, 
2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that neither you nor any 
member of your family requested the ambulance services. The Plan denied your request. The Plan says you 
were charged this cost sharing 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 $270 
copayment for each date of service regardless of the number of ambulance trips. You had 1 ambulance trip(s). 
The Plan charged you $270 for this service. 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 
ambulance services received on April 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for anticoagulant management provided on 
January 10, 2020 and March 6, 2020. 
 
You asked the Plan to waive the copayments for anticoagulant management. You say that you should only owe 
a $5 copayment per each lab service. 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 $50 
copayment for services obtained by a specialist. 
 
You received anticoagulant management on January 10, 2020 and March 6, 2020. Anticoagulant management 
is considered a specialist service. Therefore, you are responsible to pay the allowed amount of $11.34, which is 
less than the $50 copayment, per each service. The total amount you owe is: $11.34 (copayment) x 2 (specialist 
services) = $22.68.  
 
You have been asked to pay the total copayment amount of $22.68 for anticoagulant management. 
Anticoagulant management falls within the physician/practitioner services, including doctor's office visits 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayments for anticoagulant management 
provided on January 10, 2020 and March 6, 2020.