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

 
We decided that the Plan does not have to pay for the surgical pathology services coded 88305 provided on 
January 14, 2020. 
 
You asked the Plan to pay for the surgical pathology 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 supported by the 
documentation. 
 
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 88305 is Level IV - Surgical pathology, gross and 
microscopic examination Abortion - spontaneous/missed Artery, biopsy Bone marrow, biopsy Bone exostosis 
Brain/meninges, other than for tumor resection Breast, biopsy, not requiring microscopic evaluation of surgical 
margins Breast, reduction mammoplasty Bronchus, biopsy Cell block, any source Cervix, biopsy Colon, biopsy 
Duodenum, biopsy Endocervix, curettings/biopsy Endometrium, curettings/biopsy Esophagus, biopsy 
Extremity, amputation, traumatic Fallopian tube, biopsy Fallopian tube, ectopic pregnancy Femoral head, 
fracture Fingers/toes, amputation, non-traumatic Gingiva/oral mucosa, biopsy Heart valve Joint, resection 
Kidney, biopsy Larynx, biopsy Leiomyoma(s), uterine myomectomy - without uterus Lip, biopsy/wedge 
resection Lung, transbronchial biopsy Lymph node, biopsy Muscle, biopsy Nasal mucosa, biopsy 
Nasopharynx/oropharynx, biopsy Nerve, biopsy Odontogenic/dental cyst Omentum, biopsy Ovary with or 
without tube, non-neoplastic Ovary, biopsy/wedge resection Parathyroid gland Peritoneum, biopsy Pituitary 
tumor Placenta, other than third trimester Pleura/pericardium - biopsy/tissue Polyp, cervical/endometrial Polyp, 
colorectal Polyp, stomach/small intestine Prostate, needle biopsy Prostate, TUR Salivary gland, biopsy Sinus, 
paranasal biopsy Skin, other than cyst/tag/debridement/plastic repair Small intestine, biopsy Soft tissue, other 
than tumor/mass/lipoma/debridement Spleen Stomach, biopsy Synovium Testis, other than 
tumor/biopsy/castration Thyroglossal duct/brachial cleft cyst Tongue, biopsy Tonsil, biopsy Trachea, biopsy 
Ureter, biopsy Urethra, biopsy Urinary bladder, biopsy Uterus, with or without tubes and ovaries, for prolapse 
Vagina, biopsy Vulva/labia, biopsy. 
 
 
We find that CPT code 88305 is not supported in the medical record. Specifically, the documentation submitted 
does not support the units billed. A HCPCS/CPT code may be reported only if all services described by that 
code have been performed. Based on this information, we decided that Medicare rules for coverage of the 
surgical pathology services have not been met. Therefore, we decided that the Plan does not have to pay for the 
surgical pathology services coded 88305 provided on January 14, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for chiropractic services provided on November 6, 2019. 
 
You asked the Plan to waive the coinsurance for chiropractic services. You say that you were told that there 
would be no cost sharing. The Plan denied your request. The Plan says that the coinsurance you are being 
charged is correct. 
 
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 
how much you should expect to pay for Medicare-covered chiropractic services.  
 
We looked at your contract with the Plan. We did not see where the contract says enrollees must pay a 20% 
coinsurance for Medicare-covered chiropractic services. The Plan contract does not clearly say how much 
enrollees must pay for Medicare-covered chiropractic services. 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 
coinsurance for chiropractic services provided on November 6, 2019.  
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services (85610, 36415, 
84484, 84100) provided January 7, 2020 to January 10, 2020. 
 
You asked the Plan to waive the copayment for the emergency room services. You say that 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 $50 
copayment for Emergency Care.  
 
You have been asked to pay a $50 copayment for the emergency room services. The emergency room services 
fall 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 
emergency room services (85610, 36415, 84484, 84100) provided January 7, 2020 to January 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the urgent care visits provided from 
January 16, 2020 to January 26, 2020. 
 
You asked the Plan to waive the copayments for the urgent care visits. You say that you feel you should not be 
responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied 
your request. The Plan says you received urgent care visits on the dates of service at issue in this appeal. The 
Plan says that the correct copayments have applied per your contract with the Plan. 
 
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 Urgently needed services.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received urgent care visits 
on January 16, 2020, January 19, 2020, and January 26, 2020. You have been asked to pay a $50 copayment 
for each urgent care visit per your contract with the Plan. The urgent care visits fall within the Urgently needed 
services benefit category. This means that you have been asked to pay the correct amounts 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 copayments for the urgent care visits 
provided from January 16, 2020 to January 26, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 Plasma-Based Comprehensive Genomic 
Profiling testing provided on October 2, 2019 billed with multiple line items of different CPT codes. 
 
You asked the Plan to pay for the Guardant360 testing as billed. You say that this should not be denied as 
experimental as this is a proven test which is supported for this patient. The Plan denied your request. The Plan 
says on review, it was found that no payment can be made for this testing because the provider is unbundling 
when there is a single CPT code which describes this testing. 
 
The Plan must follow Medicare rules. Medicare rules say that in order to report the Guardant360 testing, one 
unit of code 81479 should be reported with the appropriate DEX Z-code.  
 
As there is a single CPT code which describes this testing, the rule for coverage of this testing as billed have 
not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 Plasma-Based 
Comprehensive Genomic Profiling testing provided on October 2, 2019 billed with multiple line items of 
different CPT codes.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397) 
provided to the enrollee on December 21, 2019. 
 
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not indicate services are necessary for treatment of the 
enrollees condition. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient?s medical 
record contains sufficient documentation of the patients medical condition to substantiate the necessity for the 
type and quantity of items ordered and for the frequency of use.  
 
The record shows that documentation submitted did not indicate the provider discussed the need for the billed 
supply code, so the billed supply code cannot be verified.  Therefore, we decided that the Plan does not have to 
pay for a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on December 21, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing provided on January 14, 2020. 
 
You asked the Plan to pay for the laboratory testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered 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 laboratory 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 
laboratory testing provided on January 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for tracheostomy supplies (A4623, A7520) provided March 8, 
2019 to March 21, 2019. 
 
You asked the Plan to pay for the tracheostomy supplies. You say that the items should be covered. The Plan 
denied your request. The Plan says payment for these items is included in payment for the SNF services. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the tracheostomy supplies was used in a SNF or hospital. Therefore, we decided that the 
Plan does not have to pay for tracheostomy supplies (A4623, A7520) provided March 8, 2019 to March 21, 
2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial exam and x-rays provided by a chiropractor on 
January 6, 2020 to May 18, 2020. 
 
You asked the Plan to pay for the exam and x-rays. You say that you had called customer service and asked if 
the plan would reimburse the costs. At the time there was never any mention of working with chiropractors out 
of the system. The Plan denied your request. The Plan says coverage for chiropractor services extends only to 
treatment by means of manual manipulation of the spine to correct a subluxation. All other services furnished 
or ordered by chiropractors are not covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the initial exam and x-rays provided by a chiropractor on January 6, 2020 to 
May 18, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for testing provided on August 16, 2019.

You asked the Plan to pay for genetic testing. You say that this testing is covered by Medicare and was medically necessary for the enrollee. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because there are no known therapeutics that could have been offered based on the results of this testing in case of uterine cancer, and the documentation submitted does not show how the outcome of testing would alter treatment of the enrollee.

The Plan follows Medicare rules. Medicare rules say that next generation sequencing testing may be covered when the above listed criteria have been met.

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 genetic testing. Our reviewer says that this testing meets the Medicare criteria for coverage. Our physician reviewer found the enrollee has a diagnosis of advanced Stage III endometrial cancer. At the time of testing, the enrollee met parameters for chemotherapy. There is no documentation of previous testing using the same next generation sequencing test. has national coverage and has been validated for all solid tumors.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genetic testing have been met. Therefore, we decided that the Plan has to pay for testing provided on August 16, 2019.

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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neuromuscular junction testing provided on March 6, 2020. 
 
You asked the Plan to pay for neuromuscular junction testing. You say that your services are performed at the 
request of the operating surgeon to ensure safety and improve outcomes. The Plan denied your request. The 
Plan says the denial of payment for this service is correct, because this service is not covered by Medicare for 
the diagnoses billed. 
 
The Plan must follow Medicare rules. Medicare rules say that procedure code 95937 is not covered when billed 
with diagnosis code M43.16.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of neuromuscular junction testing have not been met. Therefore, we decided that the Plan does not 
have to pay for neuromuscular junction testing provided on March 6, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on March 5, 2020 
and billed under code 93010. 
 
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 two claims were billed for the same service for the same enrollee. Both providers are 
within the same group and have the same specialty.  Per the Medicare Claims Processing Manual, Chapter 13, 
A/B MACs (B) generally distinguish between an interpretation and report of an x-ray or an EKG procedure 
and a review of the procedure. A professional component billing based on a review of the findings of these 
procedures, without a complete, written report similar to that which would be prepared by a specialist in the 
field, does not meet the conditions for separate payment of the service. This is because the review is already 
included in the emergency department evaluation and management (E/M) payment. The documentation 
reviewed shows an interpretation and EKG strip completed, but it was not completed by the provider of the 
denied claim. Based on the missing documentation, the recommendation for CPT code 93010 is not supported 
as a separate service.  
 
The Plan must follow Medicare rules. Medicare does not allow physicians of the same group to bill the same 
enrollee for the same type of service on the same day. In this case, the billing of code 93010 was submitted 
inappropriately due to the bundled relationship of services within the specialty group and insufficient 
information to show it was a separate and distinct service. Based on Medicare billing guidelines, this claim 
cannot be paid as billed. Therefore, we decided that the Plan does not have to pay for physician services 
provided to the enrollee on March 5, 2020 and billed under code 93010.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on January 21, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that these services should be covered as though 
they were in-network. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered 
under the Plan. 
 
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 medical services provided on January 21, 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 Guardant360' molecular pathology genomic profiling 
provided to the enrollee on April 7, 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 Medicare requires use of CPT 81479 to report a Guardant360' molecular pathology genomic 
profiling for NSCLC. 
 
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 provided to the enrollee on April 7, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 Plasma-Based Comprehensive Genomic 
Profiling testing provided on March 15, 2020 billed with multiple line items of different CPT codes. 
 
You asked the Plan to pay for the Guardant 360 testing as billed. You say that this should not be denied as 
experimental as this is a proven test which is supported for this patient. The Plan denied your request. The Plan 
says on review, it was found that no payment can be made for this testing because the provider is unbundling 
when there is a single CPT code which describes this testing. 
 
The Plan must follow Medicare rules. Medicare rules say that in order to report the Guardant360 testing, one 
unit of code 81479 should be reported with the appropriate DEX Z-code.  
 
As there is a single CPT code which describes this testing, the rule for coverage of this testing as billed have 
not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 Plasma-Based 
Comprehensive Genomic Profiling testing provided on March 15, 2020 billed with multiple line items of 
different CPT codes.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for CPT code G0480 provided on August 9, 2019. 
 
You asked the Plan to pay for CPT code G0480. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says that the medical records do not support the billing of 
CPT code G0480. 
 
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 G0480 is Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs 
and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to 
gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, 
eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other 
universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and 
variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control 
material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all 
sources, includes specimen validity testing, per day; 8-14 drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0480 is supported in the medical record. Specifically, the medical records support that 
at least 8 drug classes were tested from. Based on this information, we decided that Medicare rules for 
coverage of CPT code G0480 have been met. Therefore, we decided that the Plan has to pay for CPT code 
G0480 provided on August 9, 2019.  
 
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.