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

 
We decided that the Plan does not have to pay for unlisted molecular pathology procedure (81479) provided 
April 4, 2020. 
 
You asked the Plan to pay for unlisted molecular pathology procedure. You say that you are appealing the 
decision that this test is experimental/investigational and request the claim processed in network since you are 
the only service provider for this test. The Plan denied your request. The Plan says the records do not support 
the billed codes. 
 
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 81479 is unlisted molecular pathology procedure. 
 
We find that CPT code 81479 is not supported in the medical record. Specifically, as Comprehensive Genomic 
Profile (CGP) testing is not defined as a targeted panel by MolDX; and it is a test not currently satisfactorily 
described by any existing CPT code; to report a CGP, service providers should use CPT code 81479 (for 
the entire multi-test panel) at this time, in addition to the approved DEX Z-CodeTM entered adjacent in the 
comment/narrative field for the test; not unbundled to separate codes. Based on this information, we decided 
that Medicare rules for coverage of unlisted molecular pathology procedure have not been met. Therefore, we 
decided that the Plan does not have to pay for unlisted molecular pathology procedure (81479) provided April 
4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an ostomy pouch (A4425) and related 
supplies (A4394, A5120) received on March 17, 2020. 
 
You asked the Plan to waive the coinsurance for an ostomy pouch and related supplies. You say that these 
items are not durable medical equipment but prosthetics and that no cost-share should apply. The Plan denied 
your request. The Plan says the correct coinsurance was 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 20% 
coinsurance for each Medicare-covered prosthetic device and medical supplies.  
 
You have been asked to pay $55.40, or 20% coinsurance of the Plan-allowed amount of $276.97, for an ostomy 
pouch and related supplies. An ostomy pouch and related supplies fall within the "Prosthetic devices 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 waive the coinsurance for an ostomy pouch 
(A4425) and related supplies (A4394, A5120) received on March 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for two breast prostheses (L8030) and a 
mastectomy bra (L8000) purchased on May 8, 2020. 
 
You asked the Plan to waive the coinsurance for two breast prostheses and a mastectomy bra. You say that you 
purchased the same items last year without a liability. The Plan denied your request. The Plan says the correct 
coinsurance was 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 20% 
coinsurance for each Medicare-covered durable medical equipment item.  
 
You have been asked to pay $132.96, or 20% coinsurance of the Plan-allowed amount of $664.84, for two 
breast prostheses and a mastectomy bra. Two breast prostheses and a mastectomy bra fall within the "Durable 
medical equipment (DME) 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 waive the 
coinsurance for two breast prostheses (L8030) and a mastectomy bra (L8000) purchased on May 8, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a duplex scan provided on June 3, 2020. 
 
You asked the Plan to pay for the duplex scan. 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 
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 a duplex scan provided on June 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ophthalmology services you had on 
March 12, 2020. 
 
You asked the Plan to waive the copayment for the ophthalmology services. You say that you had a routine eye 
exam and should not have a copayment. The Plan denied your request. The Plan says you did not have a 
routine eye exam, so you were charged this copayment correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for Medicare-covered eye exams to diagnose and treat diseases of the eye.  
 
Your medical records show that you did not have a routine eye exam.  Rather, your records show that you were 
seen by your ophthalmologist as a follow-up from cataract surgery. They reviewed the opacity of your intra-
ocular lenses, which is not part of a routine eye exam. That is why you have been asked to pay a $40 
copayment for the ophthalmology services. The ophthalmology services you had fall within the Medicare-
covered eye exams 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 ophthalmology 
services you had on March 12, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient behavioral health services provided on April 23, 
2020 to May 8, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the inpatient behavioral health services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered 
benefit. 
 
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 inpatient behavioral health services provided 
on April 23, 2020 to May 8, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit (99213) on April 9, 
2020. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that the visit was needed due 
to complications from a diagnostic mammogram and that you do not agree with the copayment. The Plan 
denied your request. The Plan says the correct copayment was 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 consultation, diagnosis, or treatment by a specialist.  
 
You have been asked to pay a $40 copayment for a specialist office visit. A specialist office visit falls within 
the "Physician/Practitioner services, including doctor?s office visits" 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 (99213) on April 9, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from January 30, 2020 
through January 31, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The 
Plan denied your request. The Plan says that the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the patient clearly met criteria to believe that a two (2) midnight stay was reasonable to expect. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from January 30, 2020 through January 31, 2020.  
 
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: Favorable

 
We decided that the Plan has to pay for nursing facility care (99304, 3288F, G8483, 1123F) provided on March 
18, 2020. 
 
You asked the Plan to pay for nursing facility care. You say that this provider is recognized by Medicare. The 
Plan denied your request. The Plan says that registered nurses cannot enroll in Medicare. 
 
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 has not provided sufficient information to support that the provider was 
not eligible for Medicare at the time of service. While the Plan is correct that registered nurses are not eligible 
for Medicare enrollment, the provider at issue is a nurse practitioner that appears to be enrolled in the Medicare 
program. Therefore, we decided that the Plan has to pay for nursing facility care (99304, 3288F, G8483, 
1123F) provided on March 18, 2020.  
 
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 Guardant360 testing provided on April 21, 2020. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like reconsideration because 
the testing services were medically necessary. The Plan denied your request. The Plan says there is a more 
appropriate code to describe the provided services. 
 
The Plan must follow Medicare rules. Medicare rules say that to report a CGP service, test providers should use 
CPT code 81479 at this time. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Guardant360 testing have not been met. Specifically, CPT code 81479 is the more appropriate 
code the describe the services that were provided. Therefore, we decided that the Plan does not have to pay for 
Guardant360 testing provided on April 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a PET/CT scan of the skull base to mid-thigh provided to the 
enrollee on April 25, 2020. 
 
You asked the Plan to pay for the scan. You say that this should be paid for. The Plan denied your request. The 
Plan says the diagnosis billed is not acceptable. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans 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 pay for the scan. Our reviewer says that the services 
at issue in this case were not medically reasonable or necessary. Our physician reviewer found CMS specifies 
that specific pathologic diagnosis is necessary in order to qualify for reimbursement for PET/CT. As such 
oropharyngeal malignant neoplasm (unspecified) does not qualify. There are no chart notes or path reports 
included to retrospectively determine the actual cell type of oropharyngeal cancer that led to the request for the 
PET/CT. Therefore, per CMS guidelines reimbursement cannot be approved. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pay for a PET/CT scan of the skull base to mid-thigh provided to the enrollee on April 25, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the fundus photography with interpretation 
and report (92250) provided on February 18, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment was applied correctly to the 
services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 
copayment for all other diagnostic and nuclear medicine radiological services.  
 
You have been asked to pay $102.83 for the diagnostic radiological services provided. This is the Plan allowed 
amount which is less than the applicable copayment. 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 fundus photography with interpretation and report (92250) provided on February 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist office visit and a diagnostic hearing exam provided on May 28, 2020.

You asked the Plan to waive the copayment for the services. You say that you believe the $45 copayment for the office services was supposed to cover the payment of the hearing test. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). 

Review of the file show that you received specialist office services and a diagnostic hearing exam on May 28, 2020. You are asked to pay a $45 copayment for the specialist office services and a $45 copayment for the diagnostic hearing exam. Your EOC states that enrollees must pay a $45 copayment for each Medicare-covered diagnostic hearing exam. Your EOC also states, "enrollees must pay a $45 copayment per specialist visit. If you receive other services during the office visit, other cost-sharing may apply according to the benefit specific category in the medical benefits chart." 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 and a diagnostic hearing exam provided on May 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services provided on February 13, 2020. 
 
You asked the Plan to pay for the ophthalmological 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 
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 ophthalmological services provided on February 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a telehealth doctor's visit (99442) on May 
11, 2020. 
 
You asked the Plan to waive the copayment for a telehealth doctor's visit. You say that you are being billed 
incorrectly for the services you received. The Plan denied your request. The Plan says the correct copayment 
was 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 $10 
copayment for a primary care office visit.  
 
You have been asked to pay a $10 copayment for a telehealth doctor's visit. A telehealth doctor's visit falls 
within the "Physician/Practitioner services, including doctor's office visits" 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 telehealth doctor's visit (99442) on May 11, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for services you had with an orthopedist from 
April 13, 2020 through May 11, 2020. 
 
You asked the Plan to waive the copayments for the orthopedist services. You say that your out-of-pocket costs 
were eliminated, so these copayments should be waived. The Plan denied your request. The Plan says you were 
charged these copayments 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 $35 
copayment for diagnostic tests in a specialist?s office, and that you must pay a $35 copayment for specialist 
office visits.   
 
Records show that on April 13, 2020, you received a neck x-ray at your orthopedist?s office. You were charged 
a $35 copayment for this service. You then returned to your orthopedist on May 11, 2020. You had another 
neck x-ray as well as an office visit with your orthopedist.  You were charged a $35 copayment for the x-ray 
and a $35 copayment for the office 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. There is nothing in your file to indicate that you are not responsible for these out-of-pocket 
charges. Therefore, we decided that the Plan does not have to waive the copayments for services you had with 
an orthopedist from April 13, 2020 through May 11, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for ambulance services you received on June 
25, 2020. 
 
You asked the Plan to waive the coinsurance for the ambulance services. You say that you traveled by 
ambulance because your hips were locked.  You said that this claim should be paid in full. The Plan denied 
your request. The Plan says you were charged this coinsurance 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 5% 
coinsurance for ambulance services.  
 
You have been asked to pay 5% coinsurance for the ambulance services. 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 ambulance services you received on June 25, 2020.