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 20, 2020. 
 
You asked the Plan to pay for genetic testing. You say that this testing enabled the enrollee's treating physician 
to determine the optimal treatment pathway for the enrollee. 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 20, 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 for Guardant360 testing provided on May 20, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided on 
May 5, 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 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 CGP testing must be billed with CPT code 81479 
for date of service May 5, 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 for comprehensive genomic profile (CGP) testing provided on May 
5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from January 23, 
2020 to January 26, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you are being 
overcharged. 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 $295 
copayment for days 1-7 for inpatient hospital care.  
 
You had an inpatient hospital stay from January 23, 2020 to January 26, 2020. Therefore, you are responsible 
to pay a $295 (copayment) for days 1-3 (January 23, 2020 to January 25, 2020). $295 (copayment) x 3 
(inpatient days) = $885.  
 
You have been asked to pay the total copayment amount of $885 for an inpatient hospital stay. An inpatient 
hospital stay falls within the inpatient hospital 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 inpatient hospital stay from January 23, 2020 to January 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingivectomy or gingivoplasty (D4211) and problem 
focused limited oral evaluation (D0140) provided on June 1, 2020. 
 
You asked the Plan to pay for the gingivectomy or gingivoplasty and problem focused limited oral evaluation. 
You say that you had a cavity that caused you great pain. You also say that without the gingivectomy the cavity 
could not be reached. The Plan denied your request. The Plan says gingivectomy or gingivoplasty is not a 
covered benefit under your dental plan. The Plan also says that the problem focused limited oral evaluation 
exceeds the frequency limitation in your benefit plan. 
 
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, gingivectomy or gingivoplasty 
(D4211) is not among those covered under this benefit. The contract clearly states that problem focused limited 
oral evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a 
problem focused limited oral evaluation (D0140) on April 6, 2020, and your problem focused limited oral 
evaluation (D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for 
the gingivectomy or gingivoplasty (D4211) and problem focused limited oral evaluation (D0140) provided on 
June 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve, and straight knee 
joint addition to lower extremity. 
 
You asked the Plan to pay for the knee orthosis (L1851) and suspension sleeve (L2397), and straight knee joint 
addition to lower extremity (L2385). You say that the orthoses were medically necessary. The Plan denied your 
request. The Plan says the documentation did not include a valid physician order for the straight knee joint 
addition and the documentation submitted did not include an itemized shipping/billing invoice or proof of 
delivery for the billed date of service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
 
 
 
The record does not contain a valid physician order or proof of delivery. The claim date of service is a 
significant variation from the shipping date and date of delivery. There is no physician order for the straight 
knee joint addition. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for the knee orthosis 
and suspension sleeve, and straight knee joint addition to lower extremity.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neuromuscular junction testing provided on April 16, 
2020. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the enrollee did 
not have symptoms of weakness due to a neuromuscular junction disease. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The documentation provided shows that the enrollee received train of four testing as coded by CPT code 
95937. We find that CPT code 95937 is not supported in the medical record. Train of Four Testing does not fit 
the criteria set by CMS and Insurance Carriers for CPT 95937. There is no separate code for Train of Four 
Monitoring. Therefore, it would be inappropriate to bill the Neuromuscular Junction Testing code for Train of 
Four Monitoring. Based on this information, we decided that Medicare rules for coverage of the testing 
services have not been met. Therefore, we decided that the Plan does not have to pay for the neuromuscular 
junction testing provided on April 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
May 26, 2020 to May 30, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that this stay was related to 
a previous stay and you feel that you should not be responsible for second copayment 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 $400 
copayment per day for days 1-4 for inpatient hospital care.  
 
You had an inpatient hospital stay from May 26, 2020, to May 30, 2020. Therefore, you are responsible to pay 
a $400 copayment for days 1-4 (May 26, 2020 to May 29, 2020). $400 (copayment) x 4 (inpatient days) = 
$1,600.  
 
You have been asked to pay the total copayment amount of $1,600 for an inpatient hospital stay. An inpatient 
hospital stay falls within the inpatient hospital 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 inpatient hospital stay provided from May 26, 2020 to May 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on February 10, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
physician?s services. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on February 10, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided on 
May 5, 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 May 5, 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 May 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontics (D6241) for tooth #'s 29 & 30 and retainer 
crowns (D6751) for tooth #'s 28 & 31. 
 
You asked the Plan to pre-approve the pontics and retainer crowns. The Plan denied your request. The Plan 
says these services are not medically necessary. 
 
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. The Plan covers the pontics 
and retainer crowns when the services are medically necessary and reasonable.  
 
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 pontics and retainer crowns. Our 
reviewer says that the services do not meet coverage criteria. Our physician reviewer found there are no 
missing lower anterior teeth, and several missing lower posterior teeth including tooth #'s 17, 18, 19, 20, 30, 31 
(with #29 to be removed). Our reviewer found that the requested service is a reasonable alternative treatment 
plan, but does not rise to the level of a necessity. Our physician reviewer also found that given the Policy 
limitation as to bridges allowable only in the anterior segment, there is no necessity for the requested procedure 
of a posterior bridge from #28-31. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the pontics and retainer crowns have not been met. Therefore, we decided that 
the Plan does not have to pre-approve pontics (D6241) for tooth #'s 29 & 30 and retainer crowns (D6751) for 
tooth #'s 28 & 31.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to waive the additional copayment applied tothe application of a multi-layer compression system to the leg during an occupational therapy visit provided on March 12, 2020 billed with code 29581-GO.You asked the Plan to waive the additional copayment applied tothe compression system application... You say that it is felt that an additional copayment is not appropriate as this compression wrapping is a part of the occupational therapy plan of care and is billed as such.The Plan denied your request. The Plan says that a specialist service copayment was correctly applied to code 29581.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 says that enrollees must pay a $40 copayment for Medicare-covered occupational therapy visits.The Plan says the enrollee must pay an additional $45 copayment for specialist services provided on this date of service. However, based on the contract, the enrollee cannotbe asked to pay more than a $40 copayment for a single occupational therapy visit. The code 29581 was billed with a GO modifier indicating it was performed as part of the occupational therapy plan of care. There is no language in the contract which would create a reasonable expectation that an additional copayment would be applied to a service provided during an occupational therapy visit. There is likewise no evidence to support applying a specialist copayment to this service as it appears this care wouldhave been rendered by the same provider who performed the manual therapy.Therefore, we decided that the Plan has to waive the additional copayment applied tothe application of a multi-layer compression system to the leg during an occupational therapy visit provided on March 12, 2020 billed with code 29581-GO.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: Drugs
Decision: Favorable

We decided that the Plan has to pre-approveProlia.You asked the Plan to pre-approvethe Prolia. You say that you would like reconsideration because this drug is medically necessary.The Plan denied your request. The Plan says that the member does not meet step therapy exception criteria.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. the Plan has failed to forward medical records from the contract provider to substantiate the denial of services. It is the burden of the Medicare Health Plan to substantiate the denial with evidence. The denial is not substantiated and we must find in your favor.Therefore, we decided that the Plan has to pre-approveProlia.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 the drug testing services provided on September 19, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering 
physician?s intent that the tests be performed. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the 
drug testing services provided on September 19, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 95999) provided on July 23, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that all services which are integral to accomplishing a 
procedure are considered a component part of a comprehensive code. 
 
IONM services cannot be performed without TOF monitoring. This means that TOF testing is considered 
integral to the performance of IONM services. As such, this component of the procedure is included in 
payment for the overall IONM monitoring service which was already paid. No separate payment can be made 
for this part of the service. Therefore, we decided that the Plan does not have to pay for the services (CPT 
95999) provided on July 23, 2019.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve diagnostic medial branch blocks (MBBs), also referred to as facet 
joint injections. 
 
You asked the Plan to pre-approve the diagnostic MBBs. You say that this is a medically necessary pain 
management procedure. The Plan denied your request. The Plan says that the documentation does not show 
that the enrollee's pain is clearly from the facet joints. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint injections may be covered when provided 
for pain that is likely to be generated by the facet joints and has not been helped by conservative management.  
 
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 diagnostic MBBs. Our reviewer 
says that the documentation supports that the LCD criteria are met and that the requested MBBs are reasonable 
and necessary. Our physician reviewer found this 76-year-old man has chronic axial low back pain. His 
physical exam is compatible with facet joint syndrome. He has had facet injections in the past which have 
provided him with sustained pain relief. The request is for diagnostic MBBs as prelude to RFA. The patient 
meets the LCD criteria for diagnostic MBBs.  The requested procedure is medically reasonable and necessary. 
 
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 diagnostic MBBs have been met. Therefore, we decided that the Plan has to 
pre-approve diagnostic medial branch blocks (MBBs), also referred to as facet joint injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit for respiratory therapy care or the humidifier 
water chamber provided on February 27, 2020. 
 
You asked the Plan to pay for the home visit for respiratory therapy care (99503) and the humidifier water 
chamber (A7046). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the 
home visit code 99305 is not a valid code for Medicare purposes and there is no physician order for the 
humidifier water chamber. 
 
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 CPT code 99503 is not a valid Medicare code. The record does not contain a valid physician order 
for the humidifier water chamber provided in this case as this item is not on the order and the order was written 
after the date of service. Based on this information, we decided that Medicare rules for coverage of the home 
visit for respiratory therapy care (99503) and the humidifier water chamber (A7046) have not been met. 
Therefore, we decided that the Plan does not have to pay for the home visit for respiratory therapy care or the 
humidifier water chamber provided on February 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a back brace (L0650). 
 
You asked the Plan to pay for a back brace. You say that this was medically necessary. The Plan denied your 
request. The Plan says the proof of delivery does not support the billed date of service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery. The proof of delivery in the file show a delivery date of 
March 26, 2020. However, the billed date of service for the item at issue. The billed date of 
service is not corroborated by the proof of delivery. The record shows that the Plan made several attempts to 
obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay 
for a back brace (L0650).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on May 16, 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 May 16, 
2020.