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

We decided that the Plan does not have to pay for the Guardant360 panel rendered on February 10, 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 February 10, 2020.
Appeal type: Lab
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 February 14, 2020, and February 15, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network 
deficiency for 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 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 February 14, 2020, and February 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the six surgical placements of mini implants and implant 
/abutment supported removable denture provided on January 14, 2020. 
 
You asked the Plan to pay for the six surgical placements of mini implants and implant /abutment supported 
removable denture. You say that code D6013 was for implant supported full lower dentures, not the implants. 
You also say that the implant supported full lower dentures (D6111) was coded incorrectly. The Plan denied 
your request. The Plan says surgical placement of mini implant is not a covered benefit. The Plan also says that 
the benefits for the maxillary immediate denture have been satisfied, and the frequency limitation has been 
exceeded. 
 
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. The contract clearly states that charges for any type of implant and all 
related services are excluded from coverage. Therefore, we decided that the Plan does not have to pay for the 
six surgical placements of mini implants and implant /abutment supported removable denture provided on 
January 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF services provided on February 16, 2020 through March 
16, 2020. 
 
You asked the Plan to pay for the SNF services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says skilled services were no longer necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found as a practical matter, this member did 
not require the necessary services on an inpatient basis, in a skilled nursing facility setting beyond the last 
covered date. 
 
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 SNF services have not been met. Therefore, we decided that the Plan does 
not have to pay for SNF services provided on February 16, 2020 through March 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chiropractic office visit (99202) provided on March 4, 
2020. 
 
You asked the Plan to pay for a chiropractic office visit. You say that you were told this would be covered. The 
Plan denied your request. The Plan says this is not covered by Medicare or the Plan. 
 
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 a chiropractic office visit (99202) provided on March 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an esophagogastroduodenoscopy (43239) 
provided on June 26, 2018. 
 
You asked the Plan to waive the copayment for an esophagogastroduodenoscopy. You say that you don't agree 
with this charge. 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). Your contract with the Plan clearly says that you must pay a $200 
copayment for all outpatient surgery that is not performed during a colorectal screening.  
 
You have been asked to pay a $200 copayment for an esophagogastroduodenoscopy. This surgery was not 
performed during a colorectal screening. 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 
esophagogastroduodenoscopy (43239) provided on June 26, 2018.
Appeal type: Practitioner Services
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 arthrocentesis (20610). You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says utilization of network providers is required 
unless the Plan pre-approves out-of-network services in non-emergent situations. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis, periodic oral evaluation and x-rays provided 
on March 4, 2020. 
 
You asked the Plan to pay for the prophylaxis, periodic oral evaluation and x-rays. You say that you couldn't 
find a dentist that was covered under Medicare. You say that you were informed you could see any licensed 
dental provider and receive coverage up to $1,500. The Plan denied your request. The Plan says payment 
cannot be issued for services performed by a provider that has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
the prophylaxis, periodic oral evaluation and x-rays provided on March 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on March 5, 2020. 
 
You asked the Plan to waive the copayment for the office visit. You say that you had a wellness visit  which is 
covered by your policy with no copayment. 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 $15 
copayment for a primary care office visit.  
 
You have been asked to pay a $15 copayment for the office visit. The office visit falls within the 'Physician/ 
Practitioner services, including doctor's office visits' benefit category. The medical record shows you received 
a detailed physical exam and laboratory tests in addition to the wellness visit. 
 
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 office visit provided on March 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the periodic oral evaluation, prophylaxis, intraoral x-
ray and bitewing x-ray provided on January 28, 2020. 
 
You asked the Plan to pay more for the periodic oral evaluation, prophylaxis, intraoral x-ray and bitewing x-
ray. You say that you were informed preventive care would be covered by your dentist. The Plan denied your 
request. The Plan says the claim processed correctly. 
 
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, you are responsible for any amount 
greater than the MAC payment made by the plan when the services are received from an out-of-network 
provider.  
 
Service Billed Amount Allowed 
Amount 
Difference of 
Billed & Allowed 
Amount 
Plan Paid 
Amount 
Member 
Liability 
Periodic Oral 
Evaluation 
$62 $19 $43 $19 $43 
Prophylaxis $110 $41 $69 $41 $69 
Intraoral X-Ray $36 $11 $25 $11 $25 
Bitewing X-Ray $80 $26 $54 $26 $54 
TOTAL:     $191 
 
  
 
Therefore, we decided that the Plan does not have to pay more for the periodic oral evaluation, prophylaxis, 
intraoral x-ray and bitewing x-ray provided on January 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided on February 12, 2020.
You asked the Plan to pay for genetic testing. You say that the treating physician ordered this testing to determine if there was a more effective therapy to treat the enrollee. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this testing was not billed with the appropriate coding.
The Plan must follow Medicare rules. Medicare rules say that CGP testing should be billed with CPT code 81479 for date of service February 12, 2020. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided on February 12, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on October 1, 2019 through February 10, 2020.
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration because this code is not for durable medical equipment and the pump was not delivered to the member's home. The Plan denied your request. The Plan says CPT code S9328 is a temporary code used by a non-participating provider for services billed and it is not covered by Original Medicare.
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 S9328 is not supported in the record. Specifically, per the physician fee schedule, CPT code S9328 has a status indicator of I. This means that CPT code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) provided on October 1, 2019 through February 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 panel rendered on February 24, 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 February 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 panel rendered on March 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 is 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 March 5, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Guardant360 panel rendered on March 18, 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 March 18, 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 from March 11, 2020, to April 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
from March 11, 2020, to April 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the chiropractic services provided on February 27, 2020. 
 
You asked the Plan to pay for the chiropractic services. The Plan denied your request. The Plan says records 
were not provided. 
 
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 records for the date of 
service in question. Without 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 chiropractic services provided on February 27, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for premalignant lesion destruction (17000) provided on January 30, 2020.
You asked the Plan to pay for the premalignant lesion destruction. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 17000 is a component of column I code 17004 which has been approved and paid.
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 code the premalignant lesion destruction has a bundled relationship with code 17004 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for premalignant lesion destruction (17000) provided on January 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on February 24, 2020.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.
Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on February 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the guided tissue regeneration (D4266) and bone replacement graft for ridge preservation (D7953) provided on March 4, 2020.
You asked the Plan to pay for the guided tissue regeneration and bone replacement graft. You say that you had an extraction and some extra work done, but the extraction did not meet your deductible. You also say that the dentist billed for the extra work, and the Plan did not take into consideration the cost of the extra work. The Plan denied your request. The Plan says these services are not covered benefits.
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 guided tissue regeneration (D4266) and bone replacement graft for ridge preservation (D7953) provided on March 4, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing provided on March 2, 2020. 
 
You asked the Plan to pay for genetic testing. You say that this testing was ordered to determine if there was a 
more effective therapy to treat the enrollee. The Plan denied your request. The Plan says the denial of payment 
for this testing is correct, because this testing was not billed with the appropriate coding. 
 
The Plan must follow Medicare rules. Medicare rules say that testing must be billed with 
procedure code 81479 for date of service March 2, 2020.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for 
testing provided on March 2, 2020.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for home health services provided on February 3, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for home health 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. The 
Plan says that these services could be provided 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 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 home health services provided on February 3, 
2020 by an out of network (OON) provider.