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

 
We decided that the Plan does not have to pay for drug testing provided on April 19, 2019. 
 
You asked the Plan to pay for drug testing. You say that you are appealing with records. The Plan denied your 
request. The Plan says the denial of payment for this testing is correct, because the documentation submitted 
does not include a valid physician order, lab requisition, or medical records to support the code billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific 
lab services is required for covered lab services.  
 
We looked at the file and Medicare rules. The documentation submitted does not include a valid physician 
order or clear intent to order the specific lab service billed on this claim. Based on this information, we decided 
that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does 
not have to pay for drug testing provided on April 19, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a breast biopsy (19083) performed on 
March 22, 2019. 
 
You asked the Plan to waive the copayment for a breast biopsy. You say that you shouldn't have to pay such an 
old bill. 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 $250 
copayment for each Medicare-covered outpatient hospital facility visit.  
 
You have been asked to pay a $250 copayment for a breast biopsy. A breast biopsy falls within the "Outpatient 
hospital services" 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 breast biopsy 
(19083) performed on March 22, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab tests provided on September 3, 2019 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for lab tests. You say that you were unaware prior authorization was required. You 
say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The 
Plan says prior authorization was not obtained. 
 
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 lab tests provided on September 3, 2019 by an out 
of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for podiatry services provided on June 8, 2020. 
 
You asked the Plan to waive the copayment for podiatry services. You say that you disagree with the charges 
because you should not owe a copayment for routine foot care. 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 $15 
copayment for podiatry services.  
 
The medical records show that you received podiatry services on June 8, 2020 that went beyond routine 
services. Therefore, you are responsible to pay the $15 copayment.  
 
You have been asked to pay a $15 copayment for podiatry services. Podiatry services fall within the podiatry 
services 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 podiatry services provided 
on June 8, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on February 2, 2020 by an 
out of network (OON) provider. 
 
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 were rendered by an out-of-network provider without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The 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 laboratory services provided on February 2, 
2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve insertion of an interlaminar/interspinous process 
stabilization/distraction device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is a lack of evidence to support this device. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 device. Our reviewer says that the 
requested device is considered medically reasonable and necessary in this case. Our physician reviewer found 
current evidence based medical peer reviewed literature and long-term studies support the use of Coflex 
interlaminar stabilization with decompression as a safe and efficacious alternative to decompression and/or 
lumbar fusion for the treatment of lumbar spinal stenosis at 1 to 2 levels. The enrollee presents with reported 
severe stenosis and spondylolisthesis at the L4/5 level with severe neurogenic claudication, radiculopathy, and 
mechanical low back pain. He is worsening despite reasonable and/or comprehensive conservative treatment 
for more than 6 months. He has relief with flexion and required a cane for ambulation. Significant functional 
limitations are noted in activities of daily living. There is imaging evidence of grade 1 L4/5 spondylolisthesis 
with severe central canal, bilateral subarticular, and bilateral neuroforaminal narrowing, L5/S1 grade 1 
spondylolisthesis with severe bilateral neuroforaminal narrowing, moderate to severe central canal narrowing at 
L3/4, and mild central canal narrowing at L2/3. Authorization has been requested for lumbar decompression 
with Coflex implant at the L4/5 level. In this case, the FDA indications have not been met in the setting of 
moderate to severe to severe 3-level spinal stenosis from L3/4 through L5/S1. Therefore, this request for 
insertion of an interlaminar/interspinous process stabilization/distraction device with open decompression (CPT 
code 22867) would not be considered 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 device have been met. Therefore, we decided that the Plan has to pre-
approve insertion of an interlaminar/interspinous process stabilization/distraction device for the enrollee.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care, evaluation and management of the critically ill 
or critically injured patient; first 30-74 minutes (CPT Code 99291) provided on December 19, 2019. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Current Procedural Terminology (CPT) code 99291 (1 Unit) remains not supported. CPT code 99291represents 
Critical care, evaluation and management of the critically ill or critically injures patient, first 30-74 minutes. 
The documentation submitted do not include a critical care progress note for the billed date of service of 
December 19, 2019; therefore, the billed service cannot be verified. It is noted that multiple attempts were 
made to contact the provider for additional information. 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 critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes 
(CPT Code 99291) provided on December 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on May 6, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider 
on May 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the scanning computerized ophthalmic diagnostic imaging 
(SCODI) 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 claim is not payable as billed. 
 
The Plan must follow Medicare rules. The rules say that, effective for dates of service on and after July 1, 
2011, A/B MACs shall automatically deny claim line(s) items submitted with a GZ modifier. 
 
We looked at the file and Medicare rules. The file shows that procedure code 92134 was billed with the -GZ 
modifier. Based on this information, we decided that Medicare rules for coverage of these services have not 
been met. Therefore, we decided that the Plan does not have to pay for the scanning computerized ophthalmic 
diagnostic imaging (SCODI) rendered on February 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation, panoramic x-
ray, and extraction provided on April 29, 2019. 
 
You asked the Plan to pay for the problem focused limited oral evaluation, panoramic x-ray, and extraction. 
You say that the postal service was not available. You also say that the time limit should be waived because of 
quarantine. The Plan denied your request. The Plan says you have exceeded the limits set in the subscriber 
agreement. The Plan also says that the request for reimbursement was filed after the time limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the problem focused limited oral evaluation, panoramic x-ray, and extraction 
was not filed until May 1, 2020. This means that more than one calendar year from the date of service had 
passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the problem 
focused limited oral evaluation, panoramic x-ray, and extraction provided on April 29, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the full cost for an eye exam (92004) and premium progressive 
lenses (V2781) provided on September 18, 2019. 
 
You asked the Plan to pay the full cost for an eye exam and premium progressive lenses. You say that you 
needed these services due to a stroke. The Plan denied your request. The Plan says these services processed 
correctly. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers eye exams with a $20 copayment and covers only standard lenses. 
 
We looked at the file and the Plan's rules. The record shows that you have been asked to pay a $20 copayment 
for an eye exam. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. You are also responsible for the non-covered cost of premium progressive lenses. Based on this 
information, we decided that the Plan's rules for coverage of an eye exam and premium progressive lenses have 
not been met. Therefore, we decided that the Plan does not have to pay the full cost for an eye exam (92004) 
and premium progressive lenses (V2781) provided on September 18, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services provided by a 
participating provider on March 17, 2020 to March 25, 2020. 
 
You asked the Plan to waive the copayment for inpatient hospital services. You say that you do not agree with 
this copayment. 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 $300 
copayment per day for days 1-5. There is a $0 copayment for additional days for inpatient hospital care/in-
network.  
 
You have been asked to pay a $300 copayment per day for days 1-5. There is a $0 copayment for days 5-9 for 
inpatient hospital services. The total amount you are being asked to pay is 41,500 ($300 x 5 days = $1,500). 
Inpatient hospital services fall within the inpatient hospital care/in-network 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 inpatient hospital services provided by a participating provider on 
March 17, 2020 to March 25, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for PCR molecular urine panel testing provided on April 24, 2020. 
 
You asked the Plan to pay for laboratory testing. You say that you are appealing with records. The Plan denied 
your request. The Plan says that the denial of payment for this testing is correct, because these tests are 
experimental/investigational and not the standard of care. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 laboratory testing. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee's treating physician's plan to order both a urinalysis and vaginal probe test for 
organism DNA is a reasonable approach in this clinical situation. DNA probe testing for signs and symptoms 
of vaginitis/vaginosis is acceptable and an appropriate testing option. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of laboratory testing have been met. Therefore, we decided that the Plan has to pay 
for PCR molecular urine panel testing provided on April 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on January 8, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says it cannot be 
determined how the enrollee came to the servicing provider, or whether the services are medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or 
provider must corroborate the documentation in the beneficiary's medical documentation and confirm that 
Medicare coverage criteria have been met.  
 
We looked at the file and Medicare rules. The documentation provided does not contain medical records from 
the rendering provider for the date of service in question. Without these records, it cannot be determined that 
Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for the 
services provided on January 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for orthotic items provided on March 13, 2020. 
 
You asked the Plan to pay for orthotic items. You say that you are appealing with records. The Plan denied 
your request. The Plan says the denial of payment for these items is correct, because the documentation 
submitted does not include valid proof of delivery for the items billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the Plan sufficient 
information to determine whether payment is due for a claim. The rules say that the information submitted by 
the provider must corroborate the medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. The documentation submitted does not include valid proof of 
delivery for the specific items billed on this claim. The Plan requested this information, but it was not provided. 
Without valid proof of delivery, you have not furnished sufficient information to the Plan to justify payment of 
the claim as it has been billed. Based on this information, we decided that Medicare rules for coverage of 
orthotic items have not been met. Therefore, we decided that the Plan does not have to pay for orthotic items 
provided on March 13, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan has to waive the copayment for laboratory services provided on May 6, 2020. 
 
You asked the Plan to waive the copayment for laboratory services. You say that no testing took place. The 
Plan denied your request. The Plan says that the claims were processed correctly and you are being charged the 
correct amount. 
 
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 did not provide medical records. Without medical records we cannot 
determine whether laboratory services took place or not. Therefore, we decided that the Plan has to waive the 
copayment for laboratory services provided on May 6, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for interrogation device evaluations provided 
on February 18, 2020. 
 
You asked the Plan to waive the copayments for interrogation device evaluations. You say that you had the 
service done from home and disagree with being charged two copayments. 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 specialist services. Your contract with the Plan also clearly says that you must pay a $15 
copayment for diagnostic tests. 
 
You received interrogation device evaluations on February 18, 2020. Therefore, you are responsible to pay $15, 
which is less than the $30 copayment for the provider services and a $15 copayment for the diagnostic test 
portion. The total amount you owe is: $30.  
 
You have been asked to pay the total copayment amount of $30 for interrogation device evaluations. 
Interrogation device evaluations fall within the physician/practitioner services, including doctor's office visits 
and outpatient diagnostic tests and therapeutic services and supplies benefit categories. 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 copayments for interrogation device evaluations provided on 
February 18, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 panel rendered on May 5, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure 
code 81479. 
 
The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. Based on 
this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, 
we decided that the Plan does not have to pay for the Guardant360 panel rendered on May 5, 2020.