Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for durable medical equipment provided to the enrollee from 
June 1, 2020 to June 4, 2020. 
 
You asked the Plan to pay for this equipment. You say that this claim should be paid. The Plan denied your 
request. The Plan says code E2402 is a monthly rate on CMS fee schedule. The Explanation of Payment edit 
628 was applied indicating 'units reduced - maximum units reached' because the provider billed 20 units. CMS 
guidance and reimbursement is a monthly rental. The Plan paid 1 unit for a full month of rental for E2402.  
 
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 units billed was over the number 
of units allowed for this code. Medicare billing criteria were not met. Therefore, we decided that the Plan does 
not have to pay for durable medical equipment provided to the enrollee from June 1, 2020 to June 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to make additional payment for the home and portable oxygen 
concentrators purchased on May 5, 2020. 
 
You asked the Plan to make additional payment for the home and portable oxygen concentrators. You say that 
you were unable to get the equipment you needed in a timely manner from the network provider you were 
attempting to work with. You were forced to order this from another provider in order to ensure you had the 
oxygen you need. The Plan denied your request. The Plan says it was decided to reimburse for the oxygen 
equipment itself due to medical necessity. The payment was made leaving 20% coinsurance of the billed 
amount. However, no payment could be made for the shipping and handling. 
 
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 20% 
coinsurance for durable medical equipment and related supplies.  
 
You have been asked to pay 20% coinsurance for the home and portable oxygen concentrators. The home and 
portable oxygen concentrators fall within the durable medical equipment and related 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 make additional payment for the home and portable oxygen concentrators purchased 
on May 5, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve JAK2 (Janus kinase 2) (e.g., myeloproliferative disorder) gene 
analysis, p.Val617Phe (V617F) variant (CPT Code 81270). 
 
You asked the Plan to pre-approve the services. You say that the member needs to receive this testing to rule 
out any possible cancers, since they have been having ongoing issues for quite some time. The Plan denied 
your request. The Plan says that the service is not necessary. 
 
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 services. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found per NCCN guidelines JAK2 is indicated to rule out myeloproliferative disorder. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve JAK2 (Janus kinase 2) (e.g., myeloproliferative disorder) gene analysis, p.Val617Phe (V617F) variant 
(CPT Code 81270).  
 
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: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve PILD (0275T). 
 
You asked the Plan to pre-approve PILD. You say that you would like reconsideration because this service is 
medically necessary. The Plan denied your request. The Plan says that this service is not available to members 
of Medicare Advantage Plans. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of PILD have been met. Specifically, the record indicates that the member is enrolled in a Medicare 
approved CED study. Therefore, we decided that the Plan has to pre-approve PILD (0275T).  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on NOvember 11, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 36225 is not supported. 
 
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 36225 is selective catheter placement, subclavian or 
innominate artery, unilateral, with angiography of the ipsilateral vertebral circulation and all associated 
radiological supervision and interpretation, includes angiography of the cervicocerebral arch, when performed. 
 
We find that CPT code 36225 is not supported in the medical record. Specifically, the operative report does not 
contain documentation of a selective catheter placement into unilateral subclavian or innominate artery. 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 surgical services rendered on NOvember 11, 
2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a foot bath (A9270) performed on July 20, 2020. 
 
You asked the Plan to pay for a foot bath. You say that you should be eligible to receive some reimbursement 
from the Plan. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services.  
 
The service at issue in this appeal is a naturopathic service. Therefore, we decided that the Plan does not have 
to pay for a foot bath (A9270) performed on July 20, 2020.
Appeal type: Outpatient Therapies
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 October 30, 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 October 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory tests provided on May 26, 2020.  
 
You asked the Plan to waive the copayment for the laboratory tests. You say that the bill was incurred at your 
annual check-up which is covered entirely by insurance. You say that the additional amount should be paid. 
The Plan denied your request. The Plan says the copayment applied 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 a $10 
copayment for laboratory tests from an out-of-network laboratory facility or outpatient hospital facility. 
 
You have been asked to pay a $10 copayment for the laboratory tests. Laboratory tests falls within the 
"Outpatient diagnostic tests and therapeutic services and supplies" benefit category. Outpatient diagnostic tests 
are considered a separate service. 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 laboratory tests 
provided on May 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete upper denture (D5110) provided on August 6, 2020. 
 
You asked the Plan to pay for the dental item. You say that you were advised that the service would be paid in 
full. The Plan denied your request. The Plan says the complete upper denture 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 complete upper denture is not 
among those covered under this benefit. The record shows that the denture was approved under a different plan. 
Additionally, there is no record that a call was placed to verify your coverage prior to receiving the services. 
Therefore, we decided that the Plan does not have to pay for the complete upper denture (D5110) provided on 
August 6, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says this is 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for test materials and equipment for home 
monitoring provided on July 1, 2020. 
 
You asked the Plan to waive the copayment for the test materials and equipment for home monitoring. You say 
that you were never billed for this when you were on another insurance. The Plan denied your request. The 
Plan says the copayment applied 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 a $50 
copayment for all other diagnostic tests.  
 
You have been asked to pay a $50 copayment for the test materials and equipment for home monitoring. The 
test materials and equipment for home monitoring fall 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 test 
materials and equipment for home monitoring provided on July 1, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81286, 81404, 81407) performed. 
 
You asked the Plan to pay for the lab services. You say that the lab services were medically necessary. The 
Plan denied your request. The Plan says the claim was not submitted using the correct CPT code. 
 
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 codes 81286, 81404, & 81407 are not supported in the medical record. Specifically, per 
Medicare Local Coverage Article: Billing and Coding: MolDX: Targeted and Comprehensive Genomic Profile 
Sequencing Testing in [Solid Tumor] Cancers (A55624), Comprehensive Genomic Profile (CGP) testing is not 
described by any existing CPT code. To report a CGP service, providers should use CPT code 81479 as a 
bundled code for the entire bundled panel. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab 
services (81286, 81404, 81407) performed.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray services provided on July 23, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that the x-ray does not require a prior authorization. 
The Plan denied your request. The Plan says a 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide radiology services. The Plan did not pre-approve the services at issue. There are insufficient 
records to show the services were urgent or emergent. 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 x-ray services provided 
on July 23, 2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided. 
 
You asked the Plan to pay for the ambulance services. You say that you called to cancel the service before the 
ambulance arrival. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections (20550) provided January 10, 2020 to February 21, 
2020. 
 
You asked the Plan to pay for the injections. You say that the injections were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed CPT code. 
 
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 20550 is Injection(s); single tendon sheath, or ligament, 
aponeurosis (eg, plantar fascia). 
 
We find that CPT code 20550 is not supported in the medical record. Specifically, the record did not include 
procedure notes for the dates of service at issue. The plan made multiple requests for notes detailing the 
procedure billed, but none were received. Based on this information, we decided that Medicare rules for 
coverage of the injections have not been met. Therefore, we decided that the Plan does not have to pay for 
injections (20550) provided January 10, 2020 to February 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of the lumbar spine. 
 
You asked the Plan to pre-approve an MRI. The Plan denied your request. The Plan says an MRI is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 an MRI. Our reviewer says that the 
requested MRI is not medically reasonable and necessary. Our physician reviewer found that there is no 
documentation of adequate conservative measures, including physical therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an MRI of the lumbar spine.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an urgent care visit provided on May 22, 
2020. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that you thought you would not 
owe a copayment for a COVID-19 test. 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 $50 
copayment for urgently needed services.  
 
Please note you are not being asked to pay a copayment for a COVID-19 test.  
 
You have been asked to pay a $50 copayment for an urgent care visit. An urgent care visit falls within the 
urgently needed 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 an urgent 
care visit provided on May 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the 
requested LTACH service is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee was admitted to the current acute care hospital with respiratory 
failure, cerebral infarction, pneumonia and treated with TPA. She required tracheostomy and PEG placement as 
well as thoracentesis. The enrollee has since improved to be able to wean to trach collar but is not able to fully 
participate in physical therapy (PT) yet. The clinical notes suggest the enrollee will not likely improve 
neurologically and remains in a vegetative state. The appears to be stabilizing but requires additional short term 
acute care services which can be safely completed at the current facility. The enrollee does not require services 
at the LTACH that are not already available at the current facility. There are no services at the LTACH that the 
enrollee requires that are not already available and covered at the current facility. Therefore, this request for 
LTACH services will be considered not medically necessary at this time. Transfer to a lower level of care may 
be considered when appropriate. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.