Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for receiver (monitor), dedicated, for use with therapeutic 
glucose continuous monitor system (K0554) and supply allowance for therapeutic continuous glucose monitor 
(CGM), includes all supplies and accessories, 1 month supply = 1 unit of service (K0553) provided to the 
enrollee on January 23, 2020. 
 
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. 
The Plan says the services are not supported by the records. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the DME have not been met. Documentation submitted did not 
indicate the provider discussed the need for the billed supply code; therefore, the billed supply code cannot be 
verified. In addition, the documentation submitted did not include an itemized shipping/billing invoice to 
indicate the specific supplies, or proof of delivery. Therefore, we decided that the Plan does not have to pay for 
receiver (monitor), dedicated, for use with therapeutic glucose continuous monitor system (K0554) and supply 
allowance for therapeutic continuous glucose monitor (CGM), includes all supplies and accessories, 1 month 
supply = 1 unit of service (K0553) provided to the enrollee on January 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services coded 01936 provided on September 
26, 2019. 
 
You asked the Plan to pay for the anesthesia 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 01936 is anesthesia for percutaneous image guided 
procedures on the spine and spinal cord; therapeutic. 
 
We find that CPT code 01936 is not supported in the medical record. Specifically, this code was reported with 
a pain management procedure. Under most routine circumstances, minor pain procedures do not require 
anesthesia care other than local anesthesia. The documentation did not show any special circumstance where 
anesthesia services were required. Based on this information, we decided that Medicare rules for coverage of 
the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the 
anesthesia services coded 01936 provided on September 26, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on February 26, 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 placed 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 February 26, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit provided on 
February 16, 2020. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that you have never had to 
pay a copayment before and do not have the means to make this payment. 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 $50 
copayment for emergency care.  
 
You have been asked to pay a $50 copayment for the emergency room visit. The emergency room visit falls 
within the ?Emergency 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 the 
emergency room visit provided on February 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy service (90837) rendered by the out of 
network (OON) provider on February 25, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was provided by an out of network 
provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the psychotherapy service (90837) rendered by the out of network (OON) provider on  
February 25, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (DecisionDX-Melanoma test) provided to 
the enrollee on April 24, 2019. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the modifier billed implied a denial was expected. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee is noted to have pathology proven melanoma, with a Breslow depth of 2.27mm and a stage 
of T3b. The provided genetic testing was not necessary to diagnose, treat or prognosticate the enrollee's disease 
course. The provided testing was not medically necessary or reasonable. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for laboratory services (DecisionDX-Melanoma test) provided to the enrollee on April 24, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided to the enrollee on March 23, 2020.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you were wondering if the enrollee is hospitalized during the time of the COVID virus, if the copayment would be waived. The Plan denied your request. The Plan says the claim was processed accordingly with the member's 2019 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). The enrollee was admitted with shortness of breath from an underlying cardiac condition with an abnormal heart rhythm where the enrollee required an electrical shock to get the enrollee's heart into a normal heart rhythm. Therefore, the admission was not related to COVID-19 and the documentation indicates that the enrollee did not require COVID-19 testing. Based on this information, the claim in question was processed correctly and applied the correct cost-sharing for the service in question. The enrollee is still responsible for the cost-sharing associated with the inpatient hospital stay. Therefore, the enrollee is asked to pay a $325 copayment for the inpatient hospital care. The enrollee's EOC says that enrollees must pay a $325 copayment per admission for each medically necessary inpatient stay. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital care provided to the enrollee on March 23, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible applied for the colonoscopy (45385) provided 
on February 12, 2020. 
 
You asked the Plan to waive the deductible. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the deductible has been applied correctly to 
the service provided. 
 
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 $1000 deductible that you must pay out of pocket before the Plan 
pays their share of your covered medical services.   
 
You have been asked to pay a $1000 deductible for the colonoscopy service provided. The Plan has followed 
Medicare rules by clearly disclosing in the contract that there is a $1000 deductible required that you must pay 
out of pocket before the Plan pays their share of your covered medical services. This cost sharing is a 
contractual obligation that had not been met at the time the service was received. Therefore, we decided that 
the Plan does not have to waive the deductible applied for the colonoscopy (45385) provided on February 12, 
2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing provided on February 24, 2020. 
 
You asked the Plan to pay for the 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 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 adjacent to the code in the 
comment/narrative field. 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 
testing provided on February 24, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on March 3, 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 placed 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 March 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for infectious agent detection services (CPT 87481) provided to the enrollee on January 22, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the provider did not submit progress notes and laboratory results that are needed in order to determine the clinical utility of this testing.
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 87481 is "Infectious agent detection by nucleic acid (DNA or RNA)." We asked our coding 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found the documentation submitted does not include information from the ordering/treating physician supporting the test that was performed (87481). We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for infectious agent detection services (CPT 87481) provided to the enrollee on January 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on 
February 11, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you are appealing the 
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 $195 
copayment for each day for days 1-7 per admission.  
 
You have been asked to pay a $195 copayment for the inpatient hospital stay. The 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 
the inpatient hospital stay provided on February 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foracute inpatient rehabilitation care from June 5, 2019 through June 20, 2019.You asked the Plan to waive the copayment foracute inpatient rehabilitation care. You say that you were moved to rehab on June 5, 2019 and were there for two (2) weeks before being discharged. You state that you already paid $475 for your hospital stay but the hospital is billing you another $475 when you were never discharged.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.The rules say a plan must disclose toits enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you were admitted on June 5, 2019 to the Acute Rehab Unit for comprehensive rehabilitative due to a leftwrist fracture and left tibial plateau fracture. You were discharged on June 20, 2019. You were asked to pay a $95 copayment each day for days 1-5 for acute inpatient rehabilitation care. This means that you have been asked to pay the correct amount basedon 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 foracute inpatient rehabilitation care from June 5, 2019 through June 20, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on March 1, 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 must be entered adjacent to the CPT 
code in the comment/narrative field. Based on this information, we decided that Medicare rules for coverage of 
the Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
Guardant360 testing provided on March 1, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the services provided on February 21, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that secondary 
payment cannot be considered without the identity of or payment information from the primary payer. 
 
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 documentation provided by the plan does not provide information regarding 
the primary insurer, nor details of the Plan?s denial. Without supporting documentation, the Plan's denial 
cannot be substantiated. Therefore, we decided that the Plan has to pay for the services provided on February 
21, 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 waive the copayment for the specialist office visit provided on 
December 4, 2019. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you are not a new 
patient. 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 $40 
copayment for each specialist visit for Medicare-covered benefits.  
 
You have been asked to pay a $40 copayment for the specialist office visit. The specialist office visit falls 
within the ?Physician/Practitioner Services, including Doctor?s Office Visits? benefit category. The medical 
record shows that you were seen for hyperparathyroidism. 
 
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 specialist office visit provided on December 4, 2019.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for advance care planning services coded 36410 and ultrasound 
guidance services coded 76937 provided on September 11, 2019. 
 
You asked the Plan to pay for advance care planning services and ultrasound guidance 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 separately 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. Providers must report services with the 
appropriate CPT code. In this case, we have confirmed that code 36410 for the advance care planning services 
has a bundled relationship with code 36140 and cannot be paid as billed. This code cannot be paid as a separate 
line item.  
 
 
 
 
Also, code 76937 is a duplicate of the previously processed claim for the same date of service. Based on the 
claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have 
to pay for advance care planning services coded 36410 and ultrasound guidance services coded 76937 provided 
on September 11, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on March 4, 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 placed 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 March 4, 2020.