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

We decided that the Plan does not have to waive the copayment fora specialist visit provided on May 6, 2020.You asked the Plan to waive the copayment fora specialist visit. You say that you were not informed that copayments would be waived after May 11, 2020. You state you would have waited to see the specialist if you had known ahead of time.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 $35 copayment for services obtained by a specialist. You have been asked to pay a $35 copayment for a specialist visit. A specialist visit 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 copayment foraspecialist visit provided on May 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Guardant360 testing provided on October 11, 2019.You asked the Plan to pay forthe 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 requires the use of CPT code 81479. In addition, the appropriate DEX Z code identifier should be entered adjacent to the code 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 forthe Guardant360 testing provided on October 11, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the specialty care transport (SCT) services provided on 
February 27, 2020 billed with CPT code A0434. 
 
You asked the Plan to pay for the SCT services. You say that this claim should be paid due to the medical 
necessity of the services rendered. The Plan denied your request. The Plan says the air ambulance codes were 
approved for payment; however, code A0434 is SCT which is a ground ambulance service. 
 
The Plan must follow Medicare rules. Medicare rules say that SCT is a ground ambulance service. 
 
In this case, the claim is for air ambulance services and payment cannot be made for a ground ambulance add-
on code. Therefore, we decided that the Plan does not have to pay for the specialty care transport (SCT) 
services provided on February 27, 2020 billed with CPT code A0434.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the molecular genetic testing provided on February 3, 2020. 
 
You asked the Plan to pay for the molecular genetic 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 a covered benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The molecular genetic testing at issue in this appeal was requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay 
for the molecular genetic testing provided on February 3, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on October 7, 2019. 
 
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 requires 
the billing of code 81479. In addition, the appropriate DEX Z code identifier should be entered adjacent to the 
code 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 October 7, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiologic examination, abdomen, 1 view (74018). 
 
You asked the Plan to pay for the radiologic examination. You say that records attached supporting that this 
procedure was performed by your provider. Please review and reprocess the claim for reimbursement. The Plan 
denied your request. The Plan says the charge for this service is included in another procedure code. Medicare 
doesn't pay separately for this 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. In this case, we have confirmed that code the 
radiologic examination has a bundled relationship with code 74022 (Radiologic examination, complete acute 
abdomen series, including 2 or more views of the abdomen and a single view chest) 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 radiologic examination, 
abdomen, 1 view (74018).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic screening testing provided on February 20, 2020. 
 
You asked the Plan to pay for genetic tests. You say that the enrollee had a routine examination, and these 
services are an extension of that visit. The Plan denied your request. The Plan says the denial of payment for 
these services is correct, because these tests are not a Medicare benefit for the diagnoses listed and were 
performed for screening purposes. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The tests at issue in this appeal, genetic tests, were requested solely for screening purposes. Medicare does not 
cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to pay for 
genetic screening testing provided on February 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe implant maintenance procedures when prostheses are removed and reinserted, including cleansing of prostheses and abutments(D6080) provided on May 21, 2020.You asked the Plan to pay forthe dental service. You say that the dental service you are being charged for does not accurately describe the dental service that you actually received. You say that your implants andprosthesis were not removed or reinserted. You say that the code for a periodic oral exam better describes the service you received as you only had your teeth cleaned and polished. You also say that you would like the provider to resubmit this claim with the correct code.The Plan denied your request. The Plan says they received medical records with which the clinical review confirmed that the correct code was used when processing this claim. The Plan also says that implant maintenance procedure is not listed as a covered service.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 forthe implant maintenance procedures when prostheses are removed and reinserted, including cleansing of prostheses and abutments (D6080) provided on May 21, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transportation provided on November 1, 
2019. 
 
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says the 
ambulance services were not medically necessary. 
 
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 the ambulance services. Our reviewer says 
that the requested ambulance services were not medically reasonable and necessary. Our physician reviewer 
found that there is no documentation that the ambulance transport was medically reasonable and necessary for 
the enrollee. The enrollee appeared to be medically stable with no signs of injury or acute illness; his pain level 
was 4/10. He had no chest pain or shortness of breath and no reported cardiac history. No acute weakness was 
documented. 
 
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 ambulance services have not been met. Therefore, we decided that the Plan 
does not have to pay for the ambulance transportation provided on November 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of skin tags provided on June 3, 2020. 
 
You asked the Plan to pay for the removal of skin tags. The Plan denied your request. 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 the removal of skin tags provided on June 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for knee orthosis (L1851), a straight knee joint (L2385) and a 
suspension sleeve (L2397) provided on April 3, 2020. 
 
You asked the Plan to pay for the knee orthosis, straight knee joint and suspension sleeve. You say that you 
would like reconsideration because these supplies are medically necessary. The Plan denied your request. The 
Plan says the documentation submitted does not include an itemized shipping/billing invoice to indicate the 
specific supplies or proof of delivery for the billed date of service. 
 
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 proof of delivery for the supplies provided in this case. Specifically, the 
record does not include an itemized billing/shipping invoice to verify the billed supplies. Additionally, the 
submitted documentation does not include a proof of delivery for the billed date of service. 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 knee orthosis (L1851), a straight knee joint (L2385) and a 
suspension sleeve (L2397) provided on April 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the optometry services provided on May 13, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the optometry services. You say that you were not aware that this provider was 
out-of-network. 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided 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 optometry services provided on May 13, 2020 
by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forankle/foot orthosis (L1971) provided January 12, 2020You asked the Plan to pay forthe orthosis. You say that a thorough review of this documentation reveals that medically necessary supplies was dispensed pursuant to physician orders, which were received by the enrollee.The Plandenied your request. The Plan says the documentation submitted did not indicate the provider discussed the need for the billed supply code. Therefore, the billed supply code cannot be verified.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 orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the records do not document a weakness or deformity of the foot and ankle or that the enrollee requires stabilization for medical reasons or that she has the potential to benefit functionally from the orthosis.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 orthosis have not been met.Therefore, we decided that the Plan does not have to pay forankle/foot orthosis (L1971) provided January 12, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intermittent limb compression device (CPT Code E0676) 
provided on February 14, 2020. 
 
You asked the Plan to pay for the DME. You say that the surgeon requested this equipment to use post-surgery 
to prevent deep vein thrombosis and pulmonary embolism. The Plan denied your request. The Plan says 
Medicare does not allow payment for DME that is not for home use. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for intermittent limb compression device (CPT Code E0676) provided on February 14, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a cystourethroscopy provided by a participating facility on April 2, 2020.You asked the Plan to waive the copayment for an outpatient surgery. You say that you want to only pay for an office 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 $100 copayment for outpatient surgery/in-network. You have been asked to pay a $100 copayment for an outpatient surgery. The correct copayment has been applied to the services that were provided. An outpatient surgery falls within the outpatient surgery/in-network 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 cystourethroscopy provided by a participating facility on April 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management (99238) provided March 
27, 2020. 
 
You asked the Plan to pay for hospital discharge day management. You say that your provider provided 
medically necessary services in good faith. In consideration for the services rendered, your doctor is seeking 
reimbursement. The Plan denied your request. The Plan says only one hospital discharge day management 
service is payable per patient per hospital stay. 
 
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, a hospital discharge day management service CPT code 99238 was already billed by another 
provider and processed for payment. Only one hospital discharge day management service is payable per 
patient per hospital stay. Only the attending physician of record reports the discharge day management service. 
Based on this information, we decided that Medicare rules for coverage of hospital discharge day management 
have not been met. Therefore, we decided that the Plan does not have to pay for hospital discharge day 
management (99238) provided March 27, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance oxygen and oxygen supplies provide to the enrollee on February 12, 2020.You asked the Plan to pay forthe ambulance oxygen and oxygen supplies. You say that these services were medically necessary.The Plan denied your request. The Plan says that separate payment of ambulance supplies isnot a covered benefit.The Plan must follow Medicare rules. Medicare rules say that payment under the fee schedule for ambulance services covers both the transport of the beneficiary to the nearest appropriate facility and all items and services associated with such transport; and does not include a separate payment for items and services furnished under the ambulance benefit.Therefore, we decided that the Plan does not have to pay forthe ambulance oxygen and oxygen supplies provide to the enrollee on February 12, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided on 
November 27, 2019. 
 
You asked the Plan to pay for genetic testing. You say that the enrollee's treating physician ordered this testing 
to determine if there was a more effective therapy to treat the enrollee's condition. The Plan denied your 
request. The Plan says the denial of payment for this testing is correct, because this testing was not billed with 
the appropriate coding. 
 
The Plan must follow Medicare rules. Medicare rules say that CGP testing must be billed with CPT code 81479 
for date of service November 27, 2019.  
 
We looked at the file and Medicare rules. This testing was not billed with the appropriate coding. Based on this 
information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we 
decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided on 
November 27, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on January 2, 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 
coded with code 81479. In addition, the appropriate DEX Z code identifier should be entered adjacent to the 
code 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 January 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Transitional Care Management services (99496) provided on 
August 5, 2019. 
 
You asked the Plan to pay for the Transitional Care Management services. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says the Medicare 
rules for payment of CPT code 99496 have not been met. 
 
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 with the 
following required elements: Communication (direct contact, telephone, electronic) with the patient and/or 
caregiver within 2 business days of discharge Medical decision making of high complexity during the service 
period Face-to-face visit, within 7 calendar days of discharge.  
 
We find that CPT code 99496 is not supported in the record. Specifically, this claim was billed with place of 
service code 31 for a Skilled Nursing Facility. For Transitional Care Management services, the discharge must 
be to the member's home, a domiciliary center, rest home or nursing home or an assisted living facility. Skilled 
Nursing Facilities do not apply. Based on this information, we decided that Medicare rules for coverage of the 
Transitional Care Management services have not been met. Therefore, we decided that the Plan does not have 
to pay for Transitional Care Management services (99496) provided on August 5, 2019.