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

 
We decided that the Plan does not have to pay for the knee x-rays (73562) provided on March 5, 2020. 
 
You asked the Plan to pay for the knee x-rays. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says CPT codes 73562-26,LT and 73562-26,76,RT 
are the column II codes to the more comprehensive column I code of 73565. 
 
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 
knee x-rays has a bundled relationship with code 73565 and cannot be paid as billed. This code cannot be paid 
as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, 
we decided that the Plan does not have to pay for the knee x-rays (73562) provided on March 5, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 molecular pathology genomic profiling for 
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 Medicare requires use of CPT 81479 to report a Guardant360 molecular pathology genomic 
profiling for breast cancer. 
 
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 Guardant360 molecular pathology genomic profiling for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the office visit provided on April 20, 2020. 
 
You asked the Plan to pay for the office visit. You say that this provider is eligible to do office visits. The Plan 
denied your request. The Plan says that this provider is not eligible to perform the services billed. 
 
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's evidence regarding eligibility is not clear. The NPI registry shows the 
provider as active. Based on the information submitted, the Plan has not provided a clear explanation or 
documentation to support their denial. The Plan has not submitted convincing evidence that the license is not in 
effect. Therefore, we decided that the Plan has to pay for the office visit provided on April 20, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the destruction of malignant lesions (17281, 17282), surgical 
pathology (88305), destruction of premalignant lesions (17000, 17003), and the drug test (G0483) rendered by 
the out of network (OON) provider on February 28, 2020. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. 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 destruction of malignant lesions (17281, 17282), surgical pathology (88305), 
destruction of premalignant lesions (17000, 17003), and the drug test (G0483) rendered by the out of network 
(OON) provider on February 28, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayments for skilled nursing facility (SNF) services 
you received at an out-of-network facility from October 14, 2019 through November 23, 2019. 
 
You asked the Plan to reduce the copayments for the SNF services. You say that you feel as though the facility 
took advantage of you and didn't inform you that you would be paying the out-of-network rate. The Plan 
denied your request. The Plan says you were charged these copayments 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 $195 
copayment per day for days 1-35 for SNF care at an out-of-network facility. You pay a $0 copayment for 
additional days, up to 100 days.  
 
Records show that you were in the SNF for a total of 41 days. You were assessed a $195 copayment for each of 
the first 35 days, for a total of $6825.  Please note that you have an annual out-of-pocket maximum of $6700 
that you met during this stay. You had paid $87 towards this annual out-of-pocket maximum prior to these SNF 
services, leaving a remainder of $6613.  That is why you are being charged this amount instead of the full 
$6825 noted above. We have confirmed that the facility where you received these services was out-of-network 
with your plan,  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 reduce the copayments for skilled nursing facility (SNF) 
services you received at an out-of-network facility from October 14, 2019 through November 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on March 3, 2020. 
 
You asked the Plan to waive the copayment for an office visit. You say that the enrollee is being charged for 
office visits that never happened. The Plan denied your request. The Plan says the claims were processed 
correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollee's 
must pay a $25 copayment for each specialist visit.  
 
The medical records show that the enrollee had an office visit on March 3, 2020. Therefore, the enrollee is 
responsible to pay the $25 copayment.  
 
The enrollee has been asked to pay a $25 copayment for an office visit. An office visit falls within the 
physician/practitioner services, including doctor's office visits benefit category. This means that the enrollee 
has been asked to pay the correct amount based on their contract with the Plan. This cost sharing is a 
contractual obligation the enrollee agreed to pay when they enrolled in the Plan. Therefore, we decided that the 
Plan does not have to waive the copayment for an office visit provided on March 3, 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 code 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 April 23, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services (A0429) provided 
on May 16, 2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that the ambulance ride was 
not due to your fault. 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 $200 
copayment for each ambulance trip. You had 1 ambulance trip. The Plan charged you $200 for these 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 the ambulance services (A0429) provided on May 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nurse practitioner services provided on April 22, 2020. 
 
You asked the Plan to pay for the nurse practitioner 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 
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 nurse practitioner services provided on April 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management service (99239) provided 
February 254, 2020. 
 
You asked the Plan to pay for hospital discharge day management service. You say that this appeal should be 
granted because the services provided were medically necessary and meet all applicable professionally 
recognized standards of healthcare. The Plan denied your request. The Plan says the notice of the level 1 appeal 
decision was not provided within the required timeframe. 
 
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 99239 is hospital discharge day management service. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the history and physical 
records that was provided does not support discharge day management services and also is dated February 3, 
2020. Based on this information, we decided that Medicare rules for coverage of hospital discharge day 
management service have not been met. Therefore, we decided that the Plan does not have to pay for hospital 
discharge day management service (99239) provided February 254, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram (93000) provided 
September 19, 2019. 
 
You asked the Plan to waive the copayment for the electrocardiogram. You say that the service should be 
included in the office visit and the copayment should be waived. 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). Your contract with the Plan clearly says that you must pay a $20 
copayment for diagnostic tests.  
 
You have been asked to pay the Medicare allowable copayment of $18.17 for the electrocardiogram. The 
electrocardiogram falls within the diagnostic tests benefit category. The allowable amount is less than the $20 
noted in the Evidence of Coverage. 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 electrocardiogram 
(93000) provided September 19, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 panel rendered on May 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 claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure 
code 81479. 
 
The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. 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 Guardant360 panel rendered on May 3, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services provided on June 22, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the radiology services. You say that the study was medically necessary for the 
diagnosis and immediate treatment of the enrollee. You say that the study was performed portably because the 
enrollee is unable to travel safely or ambulate alone. The Plan denied your request. The Plan says the out of 
network services were not authorized. 
 
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 radiology services provided on June 22, 2020 by 
an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sales tax (S9999) for a walker provided April 21, 2020. 
 
You asked the Plan to pay for the sales tax. You say that the taxes should be covered. The Plan denied your 
request. The Plan says taxes are included in the fee schedule and separate payment is not made for taxes. 
 
The Plan must follow Medicare rules. Medicare rules say that plans do not make any additional payment for 
sales taxes.  
 
We looked at the file and Medicare rules. Separate payment cannot be made for sales taxes. Based on this 
information, we decided that Medicare rules for coverage of the sales tax have not been met. Therefore, we 
decided that the Plan does not have to pay for sales tax (S9999) for a walker provided April 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray of the elbow provided on June 22, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the out of network x-ray. You say that the study was medically necessary for the 
diagnosis and immediate treatment of the enrollee. You say that the study needed to be performed portably 
because the enrollee was unable to travel safely and cannot ambulate alone. The Plan denied your request. The 
Plan says the out of network services were not pre-authorized. 
 
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 an x-ray of the elbow provided on June 22, 2020 
by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Denosumab (J0897). 
 
You asked the Plan to pre-approve the Denosumab. The Plan denied your request. The Plan says the records do 
not show that you have tried a bisphosphonate. The Plan also says that the documentation does not show that 
there is a reason you cannot use a bisphosphonate. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Denosumab. Our reviewer says that 
Denosumab is not medically reasonable and necessary. Our physician reviewer found the Plan requires a trial 
of a bisphosphonate drug before they will approve the requested medication. Our reviewer found that you have 
not tried and failed the required drug. Our physician reviewer also found that there is no documentation 
provided indicating that the Plan's required drug(s) would likely be less effective and/or likely have adverse 
effects for you. 

 
 
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 Denosumab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Denosumab (J0897).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on March 29, 2020.

You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be reported with one unit of CPT 81479 and the appropriate DEX Z-Code. 

We looked at the file and Medicare rules. The requested Guardant360 testing was billed with multiple CPT codes. Per the applicable article, this testing must be reported with CPT 81479 and the appropriate DEX Z-Code. 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 the Guardant360 testing provided on March 29, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says the 
enrollee's goals were met, and there are no skilled needs. 
 
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 pre-approve continued services. Our physician 
reviewer found that from a nursing perspective, the enrollee had stable vital signs, and was treated for pain with 
effect. There are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee was at a 
contact guard to minimal assist with bed mobility and transfers. There are no identifiable skilled therapy 
service needs. She does not require skilled nursing or therapy services on a daily basis. The enrollee does not 
meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laparoscopy services with total hysterectomy. 
 
You asked the Plan to pre-approve laparoscopy services with total hysterectomy. You say that you would like 
the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve laparoscopy services with total 
hysterectomy. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee's physical exam was notable for a tender 
uterus and tender adnexa bilaterally. There is no documentation submitted discussing the rationale for the 
hysterectomy as treatment for dyspareunia or any record of any discussion with the patient about the 
risks/benefits/alternatives. Hysterectomy is not typically a treatment for dyspareunia alone unless there is 
endometriosis suspected or other pathology. The only abnormality documented is a 5 cm fibroid in the mid-
fundus. There are other therapies and diagnostics (e.g. diagnostic laparoscopy) that could be considered first if 
endometriosis is suspected. Therefore, the enrollee does not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of laparoscopy services with total hysterectomy have not been met. Therefore, we 
decided that the Plan does not have to pre-approve laparoscopy services with total hysterectomy.