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

We decided that the Plan does not have to pay for the Guardant360 testing provided on March 22, 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 March 22, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided by a 
participating provider on February 18, 2020 to February 26, 2020. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that this should be charged as a 
primary care physician copayment. The Plan denied your request. The Plan says the correct copayments have 
been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for physician services/in-network/specialist.  
 
You have been asked to pay a $20 copayment for each specialist office visit. The total amount you are being 
asked to pay is $40 ($20 x 2 visits = $40). These services were provided by an internal medicine specialist; 
therefore, the correct copayment has been applied. Specialist office visit falls within the physician services/in-
network/specialist 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 specialist office visit 
provided by a participating provider on February 18, 2020, to February 26, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on February 4, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says these services are 
not covered. 
 
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 the lab services provided on 
February 4, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy provided by a 
participating provider on May 29, 2020, to June 8, 2020. 
 
You asked the Plan to waive the copayment for physical therapy. You say that you do not agree with these 
copayments. The Plan denied your request. The Plan says the correct copayments have been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for outpatient rehabilitation services/physical therapy.  
 
You have been asked to pay a $40 copayment for each physical therapy. The total amount you are being asked 
to pay is $160 ($40 x 4 visits = $160). Physical therapy falls within the outpatient rehabilitation 
services/physical therapy 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 physical 
therapy provided by a participating provider on May 29, 2020, to June 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a 
participating provider on May 14, 2020. 
 
You asked the Plan to waive the copayment for a biopsy. You say that this procedure was done in a doctor's 
office, not a hospital. You say that you were not aware that this location was considered to be a hospital. The 
Plan denied your request. The Plan says the correct copayment has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for outpatient surgery.  
 
You have been asked to pay a $250 copayment for a biopsy. These services were provided by an outpatient 
hospital; therefore, the correct copayment has been applied. A biopsy 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 copayment for an outpatient surgery provided by a 
participating hospital on May 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a 
participating provider on April 10, 2020 to April 15, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you wanted to get 
antibiotics and then go home. You say that you were forced to stay on the floor with the corona virus patients. 
The Plan denied your request. The Plan says the correct copayment has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $245 
copayment per day for days 1-6. There is a $0 copayment for additional days for inpatient hospital care.  
 
You have been asked to pay a $245 copayment per day for days 1-5 for an inpatient hospital stay. The total 
amount you are being asked to pay is $1,225 ($245 x 5 days = $1,225). Since an inpatient hospital stay was 
provided, the correct copayment has been applied. An inpatient hospital stay falls within the inpatient hospital 
care 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 inpatient hospital stay 
provided by a participating provider on April 10, 2020 to April 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment provided by a 
participating provider on July 17, 2019, to April 16, 2020. 
 
You asked the Plan to waive the coinsurance for durable medical equipment. You say that this equipment is 
needed. The Plan denied your request. The Plan says the correct coinsurance has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for durable medical equipment.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for durable medical equipment. The 
total allowed amount is $2,375.62. The total coinsurance amount is $475.12 ($2,375.62 x 20% = $475.12). 
Please contact the Plan about payments already made and the amount left to pay. Durable medical equipment 
falls within the durable medical equipment 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 durable medical equipment provided by a participating provider on July 17, 2019, to April 16, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a positron emission tomography (PET) scan (78815) 
provided on March 12, 2020. 
 
You asked the Plan to pay for a PET scan. You say that this was medically necessary. The Plan denied your 
request. The Plan says this was not billed with an appropriate diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans must be billed with an appropriate 
diagnosis code.  
 
We looked at the file and Medicare rules. The billed diagnosis code, C67.9, is not listed as an appropriate code. 
Based on this information, we decided that Medicare rules for coverage of a PET scan have not been met. 
Therefore, we decided that the Plan does not have to pay for a positron emission tomography (PET) scan 
(78815) provided on March 12, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on December 
17, 2018. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you were not aware of the 
charges and it has affected your credit. 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 $125 
copayment for ambulance services.  
 
You have been asked to pay a $125 copayment for ambulance services. Ambulance services fall 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 ambulance services 
provided on December 17, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for myocardial perfusion imaging provided on 
May 21, 2020. 
 
You asked the Plan to waive the copayment for myocardial perfusion imaging. You say that you thought that 
copayments would be waived during the pandemic. 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 $350 
copayment for nuclear medicine services.  
 
You have been asked to pay a $350 copayment for myocardial perfusion imaging. Myocardial perfusion 
imaging 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 myocardial perfusion imaging provided on May 21, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the services rendered on October 5, 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 that the claim is not payable. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan presents conflicting information as to why the claim is not payable. It 
appears that procedure code 99223 is denied because the enrollee was not inpatient; however, the records 
support that the enrollee was under inpatient status and the claim was billed with Place of Service (POS) code 
21 for inpatient hospital. The Plan has not provided any further information or Medicare rules to support that 
the claim is not payable as billed. Therefore, we decided that the Plan has to pay for the services rendered on 
October 5, 2019.  
 
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 waive the copayment for a specialist office visit and an EKG 
provided by a participating provider on March 5, 2020. 
 
You asked the Plan to waive the copayment for a specialist office visit and an EKG. You say that you do not 
agree with these charges. The Plan denied your request. The Plan says the correct copayments have been 
applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for physician/practitioner services/specialist and a $30 copayment for outpatient diagnostic 
tests/other outpatient tests.  
 
You have been asked to pay a $20 copayment for a specialist office visit and $19.55 which is less than your 
copayment amount of $30 for an EKG. The total amount you are being asked to pay is $39.55 ($20 + $19.55 = 
$39.55). A specialist office visit falls within the physician/practitioner services/specialist benefit category and 
an EKG falls within the outpatient diagnostic tests/other outpatient tests benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for a specialist office visit and an EKG provided by a participating 
provider on March 5, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the blood count; complete (CBC) services provided on June 
14, 2020. 
 
You asked the Plan to pay for the blood count; complete (CBC) services. You say that you would like the plan 
to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
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 85027 is blood count; complete (CBC), automated (Hgb, 
Hct, RBC, WBC and platelet count). 
 
We find that CPT code 85027 is not supported in the medical record. Specifically, there is no professional 
component for this service. Therefore, this service is not payable. Based on this information, we decided that 
Medicare rules for coverage of the blood count; complete (CBC) services have not been met. Therefore, we 
decided that the Plan does not have to pay for the blood count; complete (CBC) services provided on June 14, 
2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cell examination of specimen (88112) provided on March 
24, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the cell examination of specimen. You say that you would like this request 
considered under the Radiologist, Anesthesiologist, and Pathologists (RAPS) provision. 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 cell examination of specimen (88112) 
provided on March 24, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 testing provided on March 28, 2020. 
 
You asked the Plan to pay for genetic testing. You say that the enrollee's treating physician ordered this testing 
to determine if there was a more effective therapy to treat the enrollee's condition. 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 Guardant360 testing must be billed with CPT 
code 81479 for date of service March 28, 2020.  
 
We looked at the file and Medicare rules. This testing was not billed with the appropriate coding. 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 Guardant360 testing provided on March 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral-periapical x-ray (D0220) provided on June 25, 
2020. 
 
You asked the Plan to pay for the intraoral- periapical x-ray (D0220). You say that according to the plan book, 
preventive services have a $0 copayment. You say that your book doesn't exclude any type of x-rays. The Plan 
denied your request. The Plan says the service is not a covered benefit. 
 
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 
intraoral-periapical x-ray (D0220) provided on June 25, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electroencephalogram (EEG) monitoring (95709, 95715) 
provided from April 14, 2020, to April 16, 2020. 
 
You asked the Plan to pay for EEG monitoring. You say that these services were authorized. The Plan denied 
your request. The Plan says these services were not billed correctly. 
 
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 95709 is electroencephalogram (EEG), without video, 
review of data, technical description by EEG technologist, each increment of 12-26 hours; with intermittent 
monitoring and maintenance, and 95715 is electroencephalogram with video (VEEG), review of data, technical 
description by EEG technologist, each increment of 12-26 hours; with intermittent monitoring and 
maintenance. 
 
We find that CPT codes 95709 and 95715 are not supported in the medical record. Specifically, these codes 
include the services of a technologist, and the records indicate a technologist was not dispatched for these dates 
of service.  
 
 
Based on this information, we decided that Medicare rules for coverage of EEG monitoring have not been met. 
Therefore, we decided that the Plan does not have to pay for electroencephalogram (EEG) monitoring (95709, 
95715) provided from April 14, 2020, to April 16, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on July 30, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
laboratory services. 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 laboratory services provided on July 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on December 18, 2019 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the office visit (99214). You say that you would like reconsideration because you 
were not aware that this provider was out-of-network. The Plan denied your request. The Plan says there are in-
network providers that may render this service. 
 
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 December 18, 
2019 by an out of network (OON) provider.