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

 
We decided that the Plan does not have to pay for laboratory services provided on February 10, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the Plan 
requires utilization of network providers when possible and available, and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented. 
 
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 February 10, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 17, 2020, by an 
out of network (OON) provider. 
 
You asked the Plan to pay for laboratory 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 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 laboratory services provided on January 17, 
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 deductible for an office visit provided on March 26, 2020. 
 
You asked the Plan to waive the deductible for an office visit. You say that you normally only owe $15 - $20 
and disagree with the higher 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 $110 deductible for physician/practitioner services, including doctor's 
office visits.  
 
You had an office visit on March 26, 2020. The record shows that you had paid $0 toward the $110 deductible 
prior to receiving the services. Therefore, you are responsible to pay the total allowed amount of $70.30.   
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category 
physician/practitioner services, including doctor's office visits. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $110 deductible for physician/practitioner services, including doctor's 
office visits. This cost sharing is a contractual obligation that had not been met at the time an office visit was 
received on March 26, 2020. Therefore, we decided that the Plan does not have to waive the deductible for an 
office visit provided on March 26, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded 80307 and G0483 provided on March 
27, 2020. 
 
You asked the Plan to pay for the drug testing. 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 supported by the documentation. 
 
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 80307 and G0483 are not supported in the medical record. Specifically, the place of 
service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was 
obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of 
service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was 
obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for 
coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for 
the drug testing coded 80307 and G0483 provided on March 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forgenetic testing provided on February 7, 2020 by an out of network (OON) provider.You asked the Plan to pay forgenetic testing. 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 the member'sprimary care physician did not refer these services. The Plan says that the referring provider is also out-of-network.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Planhas 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 forgenetic testing provided on February 7, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for orthotics (L1851, L2397) provided on December 31, 2019. 
 
You asked the Plan to pay for orthotics. You say that these items were medically necessary. The Plan denied 
your request. The Plan says these items were provided following an unsolicited outreach call. 
 
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 orthotics (L1851, L2397) 
provided on December 31, 2019.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health physical therapy services (G0151) home 
health occupational therapy services (G0152) home health aide services (G0156) home health direct skilled 
nursing services (G0299) provided March 3, 2020, to March 20, 2020. 
 
You asked the Plan to pay for the home health services. You say that this claim is being processed episodic and 
it is a per visit claim. Please review and reprocess the claim. The Plan denied your request. The Plan says the 
procedure code/type of bill is inconsistent with the place of service. 
 
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 type of bill submitted reflects that of a facility claim but the place of treatment is listed as the 
enrollee's home. Therefore, the procedure code/type of bill is inconsistent with the place of service.  Based on 
this information, we decided that Medicare rules for coverage of the home health services have not been met. 
Therefore, we decided that the Plan does not have to pay for the home health physical therapy services (G0151) 
home health occupational therapy services (G0152) home health aide services (G0156) home health direct 
skilled nursing services (G0299) provided March 3, 2020, to March 20, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on May 10, 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 entered adjacent to the 
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 May 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an orthosis (L0650) provided April 8, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the item was medically necessary. The Plan denied 
your request. The Plan says the documentation does not support the services billed. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery. The delivery ticket provided is not itemized and the 
delivery date does not match the dates of service billed. The record shows that the Plan made several attempts 
to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to 
pay for an orthosis (L0650) provided April 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for scanning computerized ophthalmic 
diagnostic imaging (SCODI) (91234) and ophthalmoscopy, extended (92202) provided May 20, 2020. 
 
You asked the Plan to waive the copayment for the diagnostic ophthalmology services. You say that you see 
your eye doctor every 6 months and have never had to pay more than a copay. Now you're being charged a 
coinsurance and the billing office assured you that they billed all visits the same way. The Plan denied your 
request. The Plan says the claim was processed and the correct copayment was applied per the plan 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). Your contract with the Plan clearly says that you must pay 20% of total 
allowed cost for Medicare covered diagnostic tests and procedures.  
 
You have been asked to pay $22.82 ($133.00 - $85.28 = $47.72 x 20% = $9.54 and $52.00 - $33.32 = $18.68 x 20% = 
$13.28) for the diagnostic ophthalmology services. The diagnostic ophthalmology services fall within the Outpatient 
diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when 
you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for scanning 
computerized ophthalmic diagnostic imaging (SCODI) (91234) and ophthalmoscopy, extended (92202) 
provided May 20, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on March 18, 2020. 
 
You asked the Plan to pay for drug tests. You say that you have submitted a valid order form for this testing. 
The Plan denied your request. The Plan says the denial of payment for these services is correct, because the 
documentation does not support the Place of Service (POS) code billed on this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place 
where the sample was taken is reported as the Place of Service (POS).  
 
We looked at the file and Medicare rules. The documentation submitted shows that the sample for this testing 
was taken in an office setting, therefore the Place of Service (POS) code 81 ? indicating an independent 
laboratory setting ? is not appropriate for this claim. Based on this information, we decided that Medicare rules 
for coverage of drug tests have not been met. Therefore, we decided that the Plan does not have to pay for drug 
testing provided on March 18, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic screening testing provided on January 24, 2020. 
 
You asked the Plan to pay for genetic tests. You say that the enrollee was not informed of where the analysis 
would be sent and therefore cannot be held responsible for charges. The Plan denied your request. The Plan 
says the denial of payment for these services is correct, because these tests are not a Medicare benefit for the 
diagnoses listed and were performed for screening purposes. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The tests at issue in this appeal, genetic tests, were requested solely for screening purposes. Medicare does not 
cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to pay for 
genetic screening testing provided on January 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility visit (99309) provided on July 
23, 2019, by an out of network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility visit. 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 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 subsequent nursing facility visit (99309) 
provided on July 23, 2019, 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 denture adjustment (D5411). 
 
You asked the Plan to pay for the denture adjustment (D5411). You say that the denture doesn't fit well and is 
painful when you use it. You say that you need this service. The Plan denied your request. The Plan says your 
benefits for this service are exhausted for the calendar year. 
 
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 also have a maximum benefit of 
two denture repairs per plan year. The Plan paid for a denture adjustment on January 8, 2020, and January 13, 
2020, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the denture 
adjustment (D5411).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay foran ankle-foot orthosis (L1971) provided to the enrollee on March 13, 2019.You asked the Plan to pay forthe 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 thePlan does not have to pay foran ankle-foot orthosis (L1971) provided to the enrollee on March 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 molecular pathology genomic profiling coded 
as 81120, 81121, 81201, 81210, 81235, 81275, 81311, 81173, 81270, 81293, 81400, 81401, 81401(59), 81402, 
81403, 81403(59), 81404, 81404(59), 81405, 81405(59), 81406, 81406(59), 81272, 81310, 81314, 81321 
provided January 6, 2020.  
 
You asked the Plan to pay for the Guardant360 molecular pathology genomic profiling. You say that you are 
requesting the plan reconsider this claim and provide full reimbursement against the enrollee's in-network 
benefits for Guardant360. The Plan denied your request. The Plan says there is a more appropriate code to 
describe the services provided. Providers must not unbundle the services described by a HCPCS/CPT code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, Medicare Guidance says Guardant360 testing requires use of CPT 81479 to report for liver cancer, 
and the appropriate DEX Z-Code identifier must be entered adjacent to the CPT code 81479 in the 
comment/narrative field. Based on this information, we decided that Medicare rules for coverage of the 
Guardant360 molecular pathology genomic profiling have not been met. Therefore, we decided that the Plan 
does not have to pay for Guardant360 molecular pathology genomic profiling coded as 81120, 81121, 81201, 
81210, 81235, 81275, 81311, 81173, 81270, 81293, 81400, 81401, 81401(59), 81402, 81403, 81403(59), 
81404, 81404(59), 81405, 81405(59), 81406, 81406(59), 81272, 81310, 81314, 81321 provided January 6, 
2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the excision (11606) provided on April 1, 2020. 
 
You asked the Plan to pay for the excision. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says there is a more appropriate CPT code that should be 
used to bill for the service provided. 
 
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 11606 is excision, malignant lesion including margins, 
trunk, arms, or legs; excised diameter over 4.0 cm. 
 
We find that CPT code 11606 is not supported in the record. Specifically, the record indicates that the excised 
diameter was 3cm. There is a more appropriate CPT code which should be used to bill the rendered procedure. 
Based on this information, we decided that Medicare rules for coverage of the excision have not been met. 
Therefore, we decided that the Plan does not have to pay for the excision (11606) provided on April 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the crowns provided on March 16, 2020. 
 
You asked the Plan to pay more for the crowns. You say that the crowns are not working. You say that you 
cannot afford $250. 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 also have a $125 copayment per 
crown. ($125/ crown x 2 crowns = $250). Therefore, we decided that the Plan does not have to pay more for 
the crowns provided on March 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on June 
24, 2020. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that it has been over six months 
since your last dental cleaning and checkup, and you believe this should be covered. The Plan denied your 
request. The Plan says this service exceeds the frequency limitation in your benefit 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, comprehensive oral evaluation 
(D0150) is limited to one procedure every three plan years. The record shows that you received a 
comprehensive oral evaluation (D0150) on April 12, 2018, and your comprehensive oral evaluation (D0150) 
benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive 
oral evaluation (D0150) provided on June 24, 2020.