Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic procedures (97112), electrical stimulation 
(97032), vasopneumatic devices (97016) and injections (96372, J3490, J3420, J3415 and J3411) provided on 
October 31, 2019. 
 
You asked the Plan to pay for the therapeutic procedures, electrical stimulation, vasopneumatic devices and 
injections. You say that you would like reconsideration based on the records submitted. The Plan denied your 
request. The Plan says treatment available for coverage of chiropractic care is limited to manual manipulation 
of the spine. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for therapeutic procedures (97112), electrical stimulation (97032), vasopneumatic 
devices (97016) and injections (96372, J3490, J3420, J3415 and J3411) provided on October 31, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to 
the enrollee on March 3, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this should be coded with CPT 81479. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare 
rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay 
for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on March 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on March 11, 2020. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the Guardant360 testing is not supported in the medical record. Specifically, this service should be 
billed with code 81479. In addition, the appropriate DEX Z Code identifier should be put adjacent to the CPT 
code in the comment/narrative field. Based on this information, we decided that Medicare rules for coverage of 
the Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
Guardant360 testing provided on March 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for observation services provided on October 12, 2019 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for observation services. You say that these services were medically necessary. 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 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 observation services provided on October 12, 
2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for retreatment of root canal therapy provided on April 9, 
2020. 
 
You asked the Plan to pay more for retreatment of root canal therapy. You say that the charges were pre-
authorized and you paid $807 at the time of completion. You say that the Plan should cover the additional 
charges. The Plan denied your request. The Plan says you may be billed by the out-of-network provider for any 
amount greater than the payment made by the 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, the Plan is only obligated to pay 50% 
of the allowed amount for endodontic therapy. You are responsible for any amount greater than the payment 
made by the Plan. Therefore, we decided that the Plan does not have to pay more for retreatment of root canal 
therapy provided on April 9, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram rendered on February 27, 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 a duplicate. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. 
 
We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the 
Plan on a separate claim for the same date of service. 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 electrocardiogram rendered on February 27, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 27, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that the doctor's office failed to send in a pre-
authorization form for approval. The Plan denied your request. The Plan says the enrollee must use in-network 
providers to get medical care and 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 provider at issue in this case is not a network provider with the Plan. The ordering provider is also not a 
network provider. 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 OON services. Therefore, we decided that the Plan does not have to pay for the lab services 
provided on March 27, 2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance ride provided on February 
26, 2020. 
 
You asked the Plan to waive the copayment for the ambulance ride. You say that you were told by the provider 
that you would not pay to pay for the ambulance ride. The Plan denied your request. The Plan says you have 
been charged the correct cost sharing 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 $325 
copayment for Medicare-covered ambulance services per trip.  
 
You have been asked to pay a $325 copayment for the ambulance ride. The ambulance ride falls within the 
?Ambulance 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 the 
ambulance ride provided on February 26, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a partial colectomy (44143) and mobilization of colon (44139) provided on January 12, 2020.
You asked the Plan to pay for the partial colectomy and mobilization of colon. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not indicate the exact date of service to support the services billed.
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 44143 and 44139 are not supported in the record. Specifically, the record includes multiple dates of service, but does not indicate the exact date of service to support the services billed. Additionally, CPT code 44139 is an add-on code and because primary code 44143 has been denied, separate payment for this service will not be made. Based on this information, we decided that Medicare rules for coverage of the partial colectomy and mobilization of colon have not been met. Therefore, we decided that the Plan does not have to pay for a partial colectomy (44143) and mobilization of colon (44139) provided on January 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction provided on March 10, 2020. 
 
You asked the Plan to pay for the eye refraction. You say that this provider is listed in the Plan provider 
directory as in-network. The Plan denied your request. The Plan says all eye refractions, even if you have a 
cataract surgery, must be obtained through an EyeQuest vision provider. 
 
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 
service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we 
decided that the Plan does not have to pay for an eye refraction provided on March 10, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 3, 2019 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 prior authorization may be required for outpatient diagnostic tests and services. 
 
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 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 pay for a breast biopsy (19083) provided on August 7, 2019. 
 
You asked the Plan to pay for the breast biopsy. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the documentation submitted does not support 
that this service was performed bilaterally. 
 
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 19083 is not supported in the record. Specifically, the record indicates that this service 
was rendered to the left breast. This means that the LT modifier should be appended to CPT code 19083. Based 
on this information, we decided that Medicare rules for coverage of the breast biopsy have not been met. 
Therefore, we decided that the Plan does not have to pay for a breast biopsy (19083) provided on August 7, 
2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an MRI provided on February 27, 2020. 
 
You asked the Plan to waive the copayment for an MRI. You say that you feel that the Plan should cover the 
charges because the provider is in-network. 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 $250 
copayment for advanced imaging services.  
 
You have been asked to pay the allowed amount of $216.08, which is less than the $250 copayment for an 
MRI. An MRI 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 an MRI provided on February 27, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for ultrasounds provided on March 10, 2020. 
 
You asked the Plan to waive the deductible for ultrasounds. You say that you did not know that your benefits 
changed and disagree with the 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. Your 
contract with the Plan says that there is a $500 deductible for outpatient diagnostic test and therapeutic services 
and supplies.  
 
You received ultrasounds on March 10, 2020. The record shows that you had paid $0 toward the $500 
deductible prior to receiving the services. Therefore, you are responsible to pay the allowed amount of $239.59.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient 
diagnostic test and therapeutic services and supplies. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $500 deductible for outpatient diagnostic test and therapeutic services 
and supplies. This cost sharing is a contractual obligation that had not been met at the time ultrasounds was 
received on March 10, 2020. Therefore, we decided that the Plan does not have to waive the deductible for 
ultrasounds provided on March 10, 2020.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to make additional payment for these testing services. We decided that the Plan 
does not have to provide full reimbursement for these testing services.  
 
You asked the Plan to provide full reimbursement for these testing services. You say that you feel that you 
should be reimbursed the full amount that you paid, $149. The Plan says that you were reimbursed the 
Medicare allowed rate of $32.99. 
 
We decided that the Plan has to make additional payment for these testing services.  
 
The Plan follows Medicare rules. Medicare rules say that plans must pay the correct Medicare allowable for 
testing. The rules indicate that the fee for code 86769 is $42.13 for your state. 
 
We find that the amount paid by the plan, $32.99 is incorrect. The Plan must reimburse you $42.13 for this test. 
In addition, code 86318 has a fee on the clinical laboratory fee schedule of $18.09. Code 36416 is not 
separately reimbursed since it is bundled with payment for the other services. As such, the total reimbursement 
for this testing should be $60.22 Therefore, we decided that the Plan has to make additional payment for these 
testing services.  
 
We also decided that the Plan does not have to provide full reimbursement for these testing services. 
 
The Plan follows Medicare rules. Medicare rules say that noncontract providers must accept the Medicare 
allowable as payment in full for services.  
 
With the additional reimbursement described above, the Plan will have paid the full Medicare allowable for this 
testing. This amount should be accepted as payment in full by the provider. Therefore, we decided that the Plan 
does not have to provide full reimbursement for these testing services. 
 
Please note: You may wish to contact this provider to ask for a refund of the amount they billed you in excess 
of the Medicare allowable.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for shockwave lithotripsy provided on August 9, 2019. 
 
You asked the Plan to pay for the shockwave lithotripsy. You say that you would like reconsideration because 
this service was medically necessary. The Plan denied your request. The Plan says this service is 
experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 shockwave lithotripsy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the quality of evidence for these therapies is overall low and as such, these therapies 
cannot be recommended. 
 
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 shockwave lithotripsy have not been met. Therefore, we decided that the 
Plan does not have to pay for shockwave lithotripsy provided on August 9, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee's needs can be met at a different level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. The enrollee's care needs can be met at an alternate level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI of the abdomen for the enrollee. 
 
You asked the Plan to pre-approve the MRI. You say that an MRI provides more detailed information about the 
soft tissues/inner organs than CT scan, and therefore an MRI would be more beneficial in this instance. The 
Plan denied your request. The Plan says there is no evidence or documentation of disease within the abdomen 
or pelvis that would support this MRI. 
 
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 the MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found the evaluation for 
possible primary or secondary tumor in a patient with a history of 2 prior primary malignancies is reasonable. 
The contention that MRI provides more information than CT in this instance is not true. First, MRI is very 
limited in the evaluation of the chest, especially the lungs whereas CT is ideal.  Second, the evaluation of the 
abdomen and pelvis is well addressed with CT especially in the evaluation of nodes and bowel etc.  MRI is 
limited by bowel and respiratory artifact which does not impact CT.  The enrollee's renal status is not 
mentioned in the records, but MRI has been requested with contrast, so it is assumed by the undersigned there 
is no contraindication to CT contract, because both imaging techniques and near normal GFR. No allergic 
history to iodinated contrast is mentioned to preclude CT evaluation. Also, importantly CT of the chest, 
abdomen and pelvis could be accomplished at the same sitting. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve MRI of the abdomen for the enrollee.