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

 
We decided that the Plan does not have to pay for Guardant360 testing provided on May 6, 2020. 
 
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 Guardant360 testing must be billed with CPT 
code 81479 for date of service May 6, 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 
Guardant360 testing provided on May 6, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for a Botox injection (J0585) and a 
cystourethroscopy (52287) performed on May 14, 2020. 
 
You asked the Plan to waive the cost-sharing for a Botox injection and a cystourethroscopy. You say that these 
services were necessary and have been approved before. The Plan denied your request. The Plan says the 
correct cost-sharing 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 20% 
coinsurance for Medicare Part B covered drugs and a $25 copayment for consultation, diagnosis, and treatment 
by a specialist.  
 
You have been asked to pay $122.20, or 20% coinsurance of the Plan-allowed amount of $611.00, for a Botox 
injection and a $25 copayment for a cystourethroscopy. A Botox injection falls within the "Medicare Part B 
prescription drugs" benefit category. A cystourethroscopy 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 cost-sharing for 
a Botox injection (J0585) and a cystourethroscopy (52287) performed on May 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a monitoring device (A9279) provided from April 6, 2020 to 
May 6, 2020. 
 
You asked the Plan to pay for a monitoring device. You say that this charge should be removed because you 
did not request this and it is not necessary. The Plan denied your request. The Plan says this device is not 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that claims for A9279 are denied as statutorily non-
covered. 
 
We looked at the file and Medicare rules. The item at issue is statutorily non-covered. Based on this 
information, we decided that Medicare rules for coverage of a monitoring device have not been met. Therefore, 
we decided that the Plan does not have to pay for a monitoring device (A9279) provided from April 6, 2020 to 
May 6, 2020.  
 
Your complaint about wanting to no longer receive this device is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee on September 
9, 2019. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at 
issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we 
decided that the Plan does not have to pay for the medical services provided to the enrollee on September 9, 
2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 test provided on April 14, 2020. 
 
You asked the Plan to pay for the Guardant360 test. You say that the test was medically necessary. The Plan 
denied your request. The Plan says service providers should use one CPT code not unbundle the test to separate 
codes. 
 
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 the 
Guardant360 test uses one code, 81479, and cannot be paid as billed. This code cannot be paid as separate line 
items. 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 Guardant360 test provided on April 14, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electrocardiogram (EKG) provided on March 26, 2020. 
 
You asked the Plan to pay for EKG. You say that this is a valid diagnosis for pre-operative testing. The Plan 
denied your request. The Plan says the denial of payment for this service is correct. 
 
The Plan must follow Medicare rules. Medicare rules say that EKGs performed pre-operatively, otherwise with 
no indications for the test, are not considered reasonable and necessary and are not covered.  
 
We looked at the file and Medicare rules. The record shows that this test was ordered as a routine pre-operative 
test, with no other indication listed on the order. Based on this information, we decided that Medicare rules for 
coverage of EKG have not been met. Therefore, we decided that the Plan does not have to pay for an 
electrocardiogram (EKG) provided on March 26, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided on 
March 24, 2020. 
 
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 March 24, 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 (CGP) testing provided on March 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient psychiatric hospital services 
provided from May 26, 2019 to May 27, 2019. 
 
You asked the Plan to waive the copayment for the inpatient psychiatric hospital services. The Plan denied 
your request. The Plan says that the cost sharing was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $230 
copayment per day for days 1?7 of inpatient mental health care.  
 
You have been asked to pay a $230 copayment for the inpatient hospital services. The inpatient psychiatric 
hospital services fall within the days 1?7 of inpatient mental health care benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for the inpatient psychiatric hospital services provided from May 26, 
2019 to May 27, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a surgery for removal and replacement of a 
defibrillator pulse generator (33264) performed on April 13, 2020. 
 
You asked the Plan to waive the copayment for a surgery for removal and replacement of a defibrillator pulse 
generator. You say that you feel you don't have to pay because the operation was canceled. 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 $300 
copayment for surgery in an outpatient hospital facility.  
 
You have been asked to pay a $300 copayment for a surgery for removal and replacement of a defibrillator 
pulse generator. The surgery was not successfully completed. A surgery for removal and replacement of a 
defibrillator pulse generator 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 
copayment for a surgery for removal and replacement of a defibrillator pulse generator (33264) performed on 
April 13, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for a lumbar-sacral orthosis provided on April 7, 2020. 
 
You asked the Plan to pay for lumbar-sacral orthosis. You say that you are appealing with records. The Plan 
denied your request. The Plan says that the denial of payment for this item is correct, because the 
documentation does not support the need for this item. 
 
The Plan must follow Medicare rules. Medicare rules say that a lumbar-sacral orthosis requires a written order 
prior to delivery by the supplier. The written order must contain the elements described above. 
 
We looked at the file and Medicare rules. The documentation submitted includes a written order prior to 
delivery which includes all of the necessary data elements according to Medicare coverage criteria. This item 
was ordered for a covered indication. Based on this information, we decided that Medicare rules for coverage 
of lumbar-sacral orthosis have been met. Therefore, we decided that the Plan has to pay for a lumbar-sacral 
orthosis provided on April 7, 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on May 3, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you did not request ambulance service. 
You say your new medical alert pendant was defective and activated this call. The Plan denied your request. 
The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 3, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on May 3, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 testing provided on March 11, 2020. 
 
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 Guardant360 testing must be billed with CPT 
code 81479 for date of service March 11, 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 
Guardant360 testing provided on March 11, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound scanning of blood flow 
provided on May 1, 2020. 
 
You asked the Plan to waive the copayment for an ultrasound scanning of blood flow. You say that this was 
done during your annual wellness exam and you should not be responsible for 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 $25 
copayment for carotid or peripheral vascular ultrasounds.  
 
You received an ultrasound scanning of blood flow on May 1, 2020. An ultrasound scanning of blood flow is 
not included in an annual wellness exam. Therefore, you are responsible to pay the $25 copayment.  
 
You have been asked to pay a $25 copayment for an ultrasound scanning of blood flow. An ultrasound 
scanning of blood flow 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 ultrasound scanning of blood flow provided 
on May 1, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid services 
provided on April 7, 2020. 
 
You asked the Plan to pay for the infectious agent detection by nucleic acid 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 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 infectious agent detection by nucleic acid 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 infectious agent detection by nucleic acid services provided on April 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive or reduce the cost share charged for Medicare Part B drugs 
(injections) provided on January 14, 2020. 
 
You asked the Plan to waive or reduce this coinsurance. You say that you do not believe this cost share is 
correct. The Plan denied your request. The Plan says you received a Medicare Part B drug (injection) on 
January 14, 2020. The Medicare allowable is $1904.94 multiplied by 20% coinsurance = $380.99 which is the 
cost share responsibility.   
 
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 20% 
coinsurance for Medicare Part B drugs. 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 or reduce the cost share charged for Medicare Part 
B drugs (injections) provided on January 14, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on April 30, 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 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient office visit (99214) provided 
November 20, 2019. 
 
You asked the Plan to waive the copayment for the outpatient office visit. You say that you were told that you 
owed $45 for your visit. You paid $10 because you don't feel you should have to pay $45 for someone other 
than an M.D. and your medical card indicates you must pay $45 to see an M.D and $10 for others. The Plan 
denied your request. The Plan says this claim was processed and the correct copayment was applied per the 
plan benefits. you are responsible for this copayment regardless of the person you so at the provider's office as 
the nurse practitioner sees you on the doctor's behalf 
 
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 $45 
copayment for services obtained from a specialist, or under circumstances, treatment by a nurse practitioner or 
physician's assistant or other non-physician health care professionals in a specialist's office.  
 
You have been asked to pay $45 copayment for the outpatient office visit. The outpatient office 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 for the outpatient office visit (99214) provided November 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on May 26, 2020. 
 
You asked the Plan to pay for the lumbar-sacral orthosis (L0648). You say that the orthosis was medically 
necessary. The Plan denied your request. The Plan says they were unable to discover any evidence of an 
established relationship between the member and the ordering physician. 
 
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. Review of claims history for this member, and a review of the 
submitted documentation did not contain evidence of a relationship with the ordering physician as required per 
CMS guidelines. Based on this information, we decided that Medicare rules for coverage of the lumbar-sacral 
orthosis (L0648) have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-
sacral orthosis provided on May 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on February 4, 2020 by an out 
of network provider. 
 
You asked the Plan to pay for the domiciliary or rest home visit for the evaluation and management of an 
established patient (99336). You say that the service was medically necessary. The Plan denied your request. 
The Plan says you did not request 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 has network providers 
available who can provide the services 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 medical services provided on February 4, 2020 by an out of network provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on February 13, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on February 13, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on February 13, 2020.