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

 
We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to 
the enrollee on May 14, 2020. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says Comprehensive Genomic Profile (CGP) testing (i.e. Guardant-360 and NEXT-Generation) 
requires use of CPT 81479 (for the entire multi-test panel). 
 
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 testing have not been met. Therefore, we decided that the Plan does not have to pay 
for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on May 14, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the echocardiography and Doppler echocardiography 
provided on May 1, 2020. 
 
You asked the Plan to pay for the stress test. You say that you need a stress test every 2 years for your DOT 
Certification and employment. The Plan denied your request. The Plan says this service is not covered by 
Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the stress test have not been met. Therefore, we decided that the Plan does not have to pay for the 
echocardiography and Doppler echocardiography provided on May 1, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 molecular pathology genomic profiling 
provided to the enrollee on May 11, 2020. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says this should be coded with CPT 81479. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have to pay 
for Guardant360 molecular pathology genomic profiling provided to the enrollee on May 11, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (CPT 71045) provided to the enrollee on 
April 25, 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 an appropriate modifier indicating that the service performed was distinct was not appended. 
 
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 71045 is "Radiologic examination, chest." 
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 supported by the medical records. Our physician reviewer found the 
health plan indicated that claim 8202201470609342 represents a claim by the same physician group billing 
CPT 71046 for the same date of service.  Medical records indicate that CPT 71045 was performed as a distinct, 
separate procedure from CPT 71046, however, an appropriate modifier was not appended to the CPT code to 
identify it as a separate procedure rendering it eligible for reimbursement.  Therefore, because an appropriate 
modifier was not appended to 71045, it is not eligible for reimbursement. 
 
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 radiology services (CPT 71045) provided to the enrollee on April 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the vision care you received on June 9, 
2020. 
 
You asked the Plan to waive the copayment. The Plan denied your request. The Plan says you are responsible 
for the copayment. 
 
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 each Medicare-covered exam to diagnose and treat diseases or conditions of the eye.  
 
Review of the file shows that you had a vision exam on June 9, 2020. You have been asked to pay a $50 
copayment for the services. The services fall within the vision 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 vision care you received on June 9, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
March 4, 2020 to March 18, 2020. 
 
You asked the Plan to pay for home health services. You say that you would like reconsideration because this 
claim is a per visit claim. The Plan denied your request. The Plan says the claim was processed with an 
incorrect type of bill code. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, this claim 
was submitted with an inappropriate type of bill code. Therefore, we decided that the Plan does not have to pay 
for the home health services provided to the enrollee from March 4, 2020 to March 18, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on February 20, 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 referring provider 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 February 20, 2020, by a non-network provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for physician services provided on April 9, 2020 to April 23, 2020 by an 
out-of-network provider. 
 
You asked the Plan to pay for physician services. You say that they took your insurance card so you figured 
everything would be covered. The Plan denied your request. The Plan says that prior authorization was not 
obtained. 
 
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 has failed to send in a 2020 Evidence of Coverage. Therefore, we 
decided that the Plan has to pay for physician services provided on April 9, 2020 to April 23, 2020 by an out-
of-network provider.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic nuclear medicine provided by a 
participating provider on June 8, 2020. 
 
You asked the Plan to waive the copayment for diagnostic nuclear medicine. You say that you were not 
informed that your copayment would be so high. 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 $250 
copayment for outpatient diagnostic tests/diagnostic radiology services.  
 
You have been asked to pay a $250 copayment for diagnostic nuclear medicine. The correct copayment has 
been applied to the services that were provided. Diagnostic nuclear medicine falls within the outpatient 
diagnostic tests/diagnostic radiology 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 diagnostic nuclear medicine provided by a participating provider on June 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 IRF care. Our reviewer says that the 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the 
enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. The enrollee was admitted for weakness and chest pain. 
Medical problems are stable. There are no complex nursing or rehabilitation needs. 
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in an intensive rehabilitation therapy program. The medical record supports a need for physical and 
occupational therapy but it does not support a need for an intensive rehabilitation therapy program. There is not 
a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to waive the deductible for the removal of impacted cerumen provided on June 
23, 2020. 
 
You asked the Plan to waive the deductible for the removal of impacted cerumen. You say that you disagree 
with the charges because the provider did little to help you. The Plan denied your request. The Plan says that 
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 does not say in clear and accurate terms 
which primary care physician services are subject to deductible charges. 
 
We looked at your contract with the Plan. We did not see where the contract says enrollees must pay a $750 
deductible for the removal of impacted cerumen. The Plan contract states that primary care physician services 
are not subject to cost sharing charges. The Plan contract also states that the deductible could apply to 
additional services performed on the same day within the physician's office visit but does not clearly state 
which services are subject to deductible charges. This means that the Plan did not follow Medicare rules for 
disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the deductible for the 
removal of impacted cerumen provided on June 23, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the presbyopia correcting function of intraocular lens 
(V2788) you received on June 1, 2020. 
 
You asked the Plan to pay for the lens upgrade. You say that this should be covered. The Plan denied your 
request. The Plan says this is not a covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "N" under the Physician Fee 
Schedule indicates that the code in question is non-covered.  
 
We looked at the file and Medicare rules. Code V2788 is assigned a status indicator of N under the Physician 
Fee Schedule, which means that this code is non-covered by Medicare. You do not have a supplemental benefit 
that covers this service. Based on this information, we decided that Medicare rules for coverage of the lens 
upgrade have not been met. Therefore, we decided that the Plan does not have to pay for the presbyopia 
correcting function of intraocular lens (V2788) you received on June 1, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (95886, 95908, 95999) provided on May 29, 
2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes cannot 
be verified. 
 
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 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 use 
of CPT codes 95886, 95908, and 95999 is not supported by the records provided. Our coding reviewer found 
that the technical report does not include sufficient documentation to support CPT 95886, therefore, this code 
cannot be verified. The technical report did not include CPT 95908; pedicle screw or direct root stimulations 
are not baseline nerve conduction studies, therefore this code cannot be verified. CPT 95999 cannot be 
substantiated by documentation submitted,  train of four is inclusive to the intraoperative neurophysiological 
monitoring. 
 
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 the services (95886, 95908, 95999) provided on May 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203) rendered by the out of network 
(OON) provider on July 20, 2019. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the office visit (99203) rendered by the out of network (OON) provider on July 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a podiatry office visit provided by a 
participating provider on June 17, 2020. 
 
You asked the Plan to waive the copayment for a podiatry office visit. You say that this should have a $0 
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 $40 
copayment for podiatry services.  
 
You have been asked to pay a $40 copayment for a podiatry office visit. Since additional services were 
provided, the correct copayment has been applied. A podiatry office visit falls within the podiatry 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 a podiatry office visit provided 
by a participating provider on June 17, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to 
the enrollee on May 10, 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 this should be coded with CPT 81479. 
 
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 services have not been met. Therefore, we decided that the Plan does not have to pay 
for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on May 10, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services provided on April 20, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the psychotherapy services. You say that it is your position that these services 
were required to provide this enrollee with optimum care and should be fully compensated. The Plan denied 
your request. The Plan says enrollee's must receive their medical services from an in-network provider with the 
exception being urgent or emergent services. Non-emergent services with non-contracted providers require 
prior authorization before services being rendered. 
 
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 psychotherapy services provided on April 20, 
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 physician's services provided on March 12, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
physician's 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 physician's services provided on March 12, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug test (G0483) rendered by the out of network (OON) 
provider on March 4, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the drug test (G0483) rendered by the out of network (OON) provider on March 4, 2020.