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

We decided that the Plan does not have to pay forComprehensive Genomic Profile (CGP) testing provided to the enrollee on May 4, 2020.You asked the Plan to pay forthe services. 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 CPT81479 (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 services have not been met.Therefore, we decided that the Plan does not have to pay forComprehensive Genomic Profile (CGP) testing provided to the enrollee on May 4, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 94010, CPT 94729) provided on March 
11, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for these 
services is included in the payment to the facility. 
 
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other 
than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all 
necessary covered services to the beneficiary either directly or under arrangements made with outside 
providers. Payment for all fees related to this service would have been included under the facility claim. 
Therefore, we decided that the Plan does not have to pay for the services (CPT 94010, CPT 94729) provided on 
March 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forGuardant360 testing provided on May 2, 2020.You asked the Plan to pay forgenetic testing. You say that the enrollee's treating physician ordered this testing to determine if there was a more effective therapy for the enrollee's condition.The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this testing was not billed with the appropriate coding.The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be billed with CPT code 81479 for date of service May 2, 2020. 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 forGuardant360 testing provided on May 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for hearing aids provided on June 2, 2020. 
 
You asked the Plan to reimburse you for the hearing aids. You say that you went back to this provider because 
you were familiar with the quality of the hearing aids and you were familiar and comfortable with the 
audiologist. The Plan denied your request. The Plan says you must use the in-network hearing aid provider to 
receive reimbursement. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for 
hearing aids only when provided by the Plan's hearing aid provider. 
 
We looked at the file and the Plan's rules. The file shows that you purchased the hearing aids from a provider 
that is not part of the Plan's hearing aid provider network. Based on this information, we decided that the Plan's 
rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to 
reimburse you for hearing aids provided on June 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ECG provided. 
 
You asked the Plan to waive the copayment for an ECG. You say that you already paid the office copayment 
and disagree with the additional 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 $30 
copayment for non-radiological diagnostic services.  
 
You have been asked to pay the allowed amount of $19.55, which is less than the $30 copayment for an ECG. 
An ECG 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 ECG provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on May 11, 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 
physicians 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 May 11, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a participating provider hospital on June 20, 2020.You asked the Plan to waive the copayment foran emergency room visit. You say that you tried to call your doctor but he wouldn't answer so you went to the emergency room because that's what you were told to do. 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 $120 copayment for emergency care. You have been asked to pay a $120 copayment for an emergency room visit. Since an emergency room visit did occur, the correct copayment has been applied. An emergency room visit falls within the emergency 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 an emergency roomvisit provided by a participating provider hospital on June 20, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit (99214), tangential biopsy 
of the skin (11102, 11103), and the destruction of premalignant lesions (17000, 17003) provided on June 15, 
2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the services provided. 
 
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 each visit to a specialty physician office.  
 
You have been asked to pay a $20 copayment for the specialty physician office visit provided. 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 office visit (99214), tangential biopsy of the skin (11102, 11103), 
and the destruction of premalignant lesions (17000, 17003) provided on June 15, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on February 28, 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 services are not covered. 
 
The Plan must follow Medicare rules. The rules say that the use of a telecommunications system may substitute 
for an in-person encounter for professional consultations, office visits, office psychiatry services, and a limited 
number of other physician fee schedule (PFS) services. 
 
The file shows that the laboratory services at issue were ordered via telehealth. Medicare does not allow for 
these services to be ordered via telehealth. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on February 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat (E0244). 
 
You asked the Plan to pre-approve a raised toilet seat. You say that the raised toilet seat is medically necessary. 
The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While a raised toilet seat may be appropriate, neither the Plan nor Medicare offers coverage of 
this item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat (E0244).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the complete upper and lower denture. 
 
You asked the Plan to pre-approve the complete upper and lower denture. You say that the first set of dentures 
were never properly installed. You say that you shouldn't have to pay for the mistake of the dentist so the full 
dentures should be covered. The Plan denied your request. The Plan says denture coverage is limited to 1 set in 
a 5-year period. 
 
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, you also have a maximum benefit of 
one denture every 5 years. The Plan paid for partial dentures provided on June 11, 2018, which exhausted your 
benefit. Therefore, we decided that the Plan does not have to pre-approve the complete upper and lower 
denture.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the purchase of an Inogen portable oxygen concentrator 
(E1392). 
 
You asked the Plan to pre-approve the portable oxygen concentrator. You say that you need the new 
concentrator because it is lighter to carry. The Plan denied your request. The Plan says this equipment is not 
covered for purchase. 
 
The Plan must follow Medicare rules. Medicare rules say that only rented oxygen equipment is eligible for 
coverage.  
 
We looked at the file and Medicare rules. The request is to purchase oxygen equipment. Only rented equipment 
is covered. Based on this information, we decided that Medicare rules for coverage of the portable oxygen 
concentrator have not been met. Therefore, we decided that the Plan does not have to pre-approve the purchase 
of an Inogen portable oxygen concentrator (E1392).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that you would like reconsideration because 
the home ventilator is medically necessary. The Plan denied your request. The Plan says the records do not 
show that the member has ongoing breathing failure with high C02 blood levels. 
 
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 the home ventilator. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this system is not considered a true ventilator.  It provides pressurized O2 and 
purports to enhance ventilation during activity.  There are no convincing data of efficacy.  Additionally, this 
member does not have a covered diagnosis for a home ventilator. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the destruction of a lesion provided on June 
9, 2020. 
 
You asked the Plan to waive the copayment for the destruction of a lesion. You say that you only had a few 
spots removed and did not have an outpatient surgical procedure. 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 $200 
copayment for outpatient hospital surgery services for outpatient surgery, including services provided at 
hospital outpatient facilities. 
 
You received the destruction of a lesion on June 9, 2020. The destruction of a lesion is considered an outpatient 
surgical procedure. Therefore, you are responsible to pay the allowed amount of $186.83, which is less than the 
$200 copayment.   
 
You have been asked to pay $186.83 for the destruction of a lesion. The destruction of a lesion 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 the destruction of a lesion 
provided on June 9, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wheelchair van transport (A0130) provided February 12, 
2020 to February 19, 2020. 
 
You asked the Plan to pay for the wheelchair van transport. You say that the service was medically necessary. 
The Plan denied your request. The Plan says wheelchair van transportation is not a covered service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided 
that the Plan does not have to pay for wheelchair van transport (A0130) provided February 12, 2020 to 
February 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that the enrollee has muscle aches, joint pain, 
swelling in the extremities and difficulty walking. The Plan denied your request. The Plan says this item is not 
a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodic oral evaluation, bitewings, first intraoral periapical x-ray, additional intraoral periapical x-ray, and prophylaxis provided on January 16, 2020 by you, an OON provider.You asked the Plan to pay forthe periodic oral evaluation, bitewings, intraoral periapical x-rays, and prophylaxis. You say that before rendering the services, you verified the enrollee's eligibility with the Plan, and this representative told you the enrollee's plan covered preventive services that were provided by in-network providers. You also say that you later spoke to another representative who told you that you are not in-network with the enrollee's Plan.The Plan denied your request. The Plan says you are an OON provider with the enrollee's plan. The Plan also says that these services are not covered when they are performed by an OONprovider.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 covered when they are received OON.Therefore, we decided that the Plan does not have to pay forthe periodic oral evaluation, bitewings, first intraoral periapical x-ray, additional intraoral periapical x-ray, and prophylaxis provided on January 16, 2020 by you, an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on January 30, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 64702 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 64702 and 26356. Code 64702 is a column II code with a 
modifier indicator of 1 when billed with column I code 26356. Code 64702 was not billed with an appropriate 
modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the 
surgical services rendered on January 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on April 21, 2020. 
 
You asked the Plan to pay for the domiciliary, rest home visit. 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 a domiciliary, rest home visit provided on April 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology servicesprovided on March 10, 2020.You asked the Plan to pay for the diagnostic radiology services. The Plan denied your request. The Plan says 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 servicesat 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 diagnostic radiology services provided on March 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need further therapy to regain movement. The 
Plan denied your request. The Plan says you are stable medically, and surgery was uncomplicated. 
 
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 physician reviewer found 
that you are at a minimal assist level for ambulation using a rolling walker, and moderate assist for lower body 
dressing. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does not currently 
require intensive physician and nursing oversight only in an IRF. You may benefit from physical and 
occupational therapy, but the documentation does not support that your functional status requires an 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings (A6530). 
 
You asked the Plan to pre-approve the compression stockings. You say that the stockings are medically 
necessary. The Plan denied your request. The Plan says this item is not covered. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings (A6530).