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

 
We decided that the Plan does not have to waive the coinsurance for the outpatient surgery services provided 
on June 4, 2020. 
 
You asked the Plan to waive the coinsurance for the colonoscopy. You say that you should not have a 
copayment. The Plan denied your request. The Plan says you have been charged this copayment correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $475 
copayment for outpatient surgery.  
 
You have been asked to pay $475 copayment for the colonoscopy. the colonoscopy falls within the outpatient 
surgery 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 coinsurance for the outpatient surgery 
services provided on June 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forlaboratory services provided to the enrollee on January 22, 2020.You asked the Planto pay forthe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthere is no established relationship between the enrollee and the ordering provider.The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem. The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met.Therefore, we decided that the Plandoes not haveto pay forlaboratory services provided to the enrollee on January 22, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home health services provided to the enrollee from April 21, 2020.You asked the Plan to pay forhomehealth services. You say that you would like reconsideration because this is a per visit claim.The Plan denied your request. The Plan says the claim was submitted with an invalid HIPPS code.The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, per CMS guidelines, this claim was not submitted with a valid HIPPS code.Therefore, we decided that the Plan does not have to pay forthe home health services provided to the enrollee fromApril 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endodontic therapy (D3320) provided on March 4, 2020. 
 
You asked the Plan to pay for the endodontic therapy. You say that you were advised that the services you 
received would be covered. You also say that you received a bill that showed the insurance did not cover the 
services at all. The Plan denied your request. The Plan says endodontic therapy is not listed as a covered 
service. 
 
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 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
endodontic therapy (D3320) provided on March 4, 2020.
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 14, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are 
available in-network. 
 
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 14, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on March 5, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for transvaginal and pelvic ultrasounds (76830 and 76856). You say that you would 
like reconsideration because the services rendered were medically necessary. The Plan denied your request. 
The Plan says utilization of network providers is required when possible and available. 
 
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 March 5, 2020 
by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on December 4, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe subsequent nursing facility services (99309). You say that you would like reconsideration because the services rendered were medically necessary.The Plan deniedyour request. The Plan says the member does not have out-of-network benefits.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 issuein 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 forthe medical services provided on December 4, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on December 19, 2019 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that you are in-network. You say that you would like 
this claim reprocessed and approved for payment. The Plan denied your request. The Plan says these services 
were provided by a nonparticipating provider. The Plan says that the member's primary care physician did not 
refer these services. 
 
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 physician services provided on December 19, 
2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on May 12, 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 12, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on May 14, 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 14, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the office visit (99213) provided on June 8, 
2020. 
 
You asked the Plan to waive the cost share. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the cost share has been applied correctly to the 
service 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 $500 
out of network yearly deductible. After the deductible is met, you pay 30% for each out of network Medicare-
covered visit with a PCP or specialist.  
 
You have been asked to pay $77.59 for the out of network specialist office visit provided. This amount is the 
Plan allowed amount, which has been applied to the out of network yearly deductible. As of this date of 
service, the yearly out of network deductible of $500 has not been met. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
cost share for the office visit (99213) provided on June 8, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 19, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are 
not covered. 
 
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 testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this 
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab 
services provided on March 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for morphometric analysis (88377, 88368 and 88369) provided 
on April 9, 2020. 
 
You asked the Plan to pay for the morphometric analysis. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says these codes are column II procedures to the 
column I procedure, 81219, 81270, billed by the same provider. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that codes the 
morphometric analysis have a bundled relationship with code 81219 and cannot be paid as billed. These codes 
cannot be paid as separate line items. Based on the claim submitted, Medicare billing criteria have not been 
met. Therefore, we decided that the Plan does not have to pay for morphometric analysis (88377, 88368 and 
88369) provided on April 9, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the copayments for the debridement services (11043) and the 
whole body bone imaging (78306) provided on October 28, 2019 and January 30, 2020. 
 
You asked the Plan to adjust the copayments for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayments 
have 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 $250 
copayment per day for outpatient procedures and services, including, but not limited to, outpatient surgery 
performed in an outpatient hospital or ambulatory surgical center.  
 
You have been asked to pay $500 ($250 copayment x 2 days) for the outpatient services performed in an 
outpatient hospital. 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 upon enrolling in the Plan. Therefore, 
we decided that the Plan does not have to adjust the copayments for the debridement services (11043) and the 
whole body bone imaging (78306) provided on October 28, 2019 and January 30, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on May 19, 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 19, 
2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for MRI, spinal canal and contents, lumbar; without contrast 
material (CPT Code 72148) provided on March 10, 2020. 
 
You asked the Plan to pay for the MRI. You say that the claim should be paid. The Plan denied your request. 
The Plan says the referring provider has been excluded/sanctioned by the Office of Inspector General U.S. 
Department of Health and Human Services with no reinstatement date and the rendering provider should 
ensure, at point of service, that the ordering or prescribing physician is not excluded. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the MRI have not been met. The services were ordered by a 
provider that?s been sanctioned/excluded from the Medicare program. The rules say that section 1128 of the 
Social Security Act provides the authority to Medicare to exclude various health care providers from receiving 
payment under Medicare. When an exclusion is imposed, no payment is made to anyone for any items or 
services in any capacity furnished, ordered, or prescribed by an excluded party under the Medicare, Medicaid, 
and all federal health care programs. In addition, no payment is made to any business or facility, e.g., a 
hospital, that submits claims for payment of items or services provided, ordered, prescribed, or referred by an 
excluded party. Therefore, we decided that the Plan does not have to pay for MRI, spinal canal and contents, 
lumbar; without contrast material (CPT Code 72148) provided on March 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a medical eye exam (92014) provided on 
May 26, 2020. 
 
You asked the Plan to waive the copayment for a medical eye exam. You say that the enrollee should not have 
had a copayment. The Plan denied your request. The Plan says this processed correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $20 copayment for Medicare-covered eye exams to diagnose and treat diseases and conditions of 
the eyes.  
 
The enrollee has been asked to pay a $20 copayment for a medical eye exam. This means that the enrollee has 
been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayment for a medical eye exam (92014) provided on May 26, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network 
provider on May 23, 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 services provided to the enrollee by an out-of-network provider on May 
23, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic radiology, MRI services 
(72197) provided June 4, 2020. 
 
You asked the Plan to waive the copayment for the MRI services. You say that you were not made aware or 
informed that you was to pay a copay for the diagnostic radiology services. The Plan denied your request. The 
Plan says the correct copayment was applied per the plan benefits. 
 
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 $325 per 
day for Medicare covered diagnostic radiology services.  
 
You have been asked to pay $325 for the MRI services. The MRI services 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 the diagnostic radiology, MRI services (72197) provided June 4, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 27, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. 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 by the 
facility or the provider; therefore, payment has been correctly denied. 
 
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 March 27, 
2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay formolecular pathology services (HCPCS G0452) provided to the enrollee on April 28, 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 modifier TC cannot be used in this case.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 HCPCS code G0452 is "molecular pathology procedure; physician interpretation and report."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 the services. Our reviewer says that the services at issue in this case were supported by the medical records. Our physician reviewer found HCPCS G0452-59 is the incorrect modifier to bill for this service. Modifier 26 Professional Component is the correct modifier to report with this code.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 services have not been met.Therefore, we decided that the Plan does not have to pay formolecular pathology services (HCPCS G0452) provided to the enrollee on April 28, 2020.