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

 
We decided that the Plan does not have to pay for the genetic testing provided on December 13, 2021 billed 
with codes 87653, 87500, 87481, and 87641. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
December 13, 2021 billed with codes 87653, 87500, 87481, and 87641.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (82306, 80053, 84443, G0471) provided on May 
25, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the out-of-network services were not pre-authorized or emergent. 
 
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 had network providers available who could have provided the services 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 these services. Therefore, we decided 
that the Plan does not have to pay for lab services (82306, 80053, 84443, G0471) provided on May 25, 2022 by 
an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a kidney procedure provided on April 4, 
2022. 
 
You asked the Plan to waive the copayment for a kidney procedure. You say that this copayment is too costly. 
The Plan denied your request. The Plan says the copayment was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 
copayment for outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital facility.  
 
You have been asked to pay a $200 copayment for a kidney procedure. A kidney procedure falls within the 
Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers 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 kidney procedure 
provided on April 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit on April 24, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you believe that copayment should be 
$10. The Plan denied your request. The Plan says the cost sharing you are being charged is correct. 
 
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 $45 
copayment for services performed with a specialist for Medicare-covered services or provided by other health 
care professionals such as nurse practitioners, physician assistants, etc. Covered services include consultation, 
diagnosis, and treatment by a specialist.  
 
 
 
 
 You have been asked to pay a $45 copayment for office visit. Office visits fall 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 office visit on April 24, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to reimburse you for a COVID-19 at-home test kit provided on April 11, 2022. 
 
You asked the Plan to reimburse you for a COVID-19 at-home test kit. The Plan denied your request. The Plan 
says that the test does not fall in the effective term date for benefit coverage. 
 
The Plan must follow Medicare rules. 
 
We looked at the file and Medicare rules. Medicare covers COVID-19 at-home test kits starting April 4, 2022 
and continues until the COVID-19 public health emergency (PHE) ends, people with Medicare Part B can get 
up to eight free over-the-counter tests for the month of April any time before April 30
th
 and can then get 
another set of eight free over-the-counter tests during each subsequent calendar month through the end of the 
COVID-19 PHE. Based on this information, we decided that Medicare rules for coverage of a COVID-19 at-
home test kit have been met. Therefore, we decided that the Plan has to reimburse you for a COVID-19 at-
home test kit provided on April 11, 2022.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the MRI provided on May 7, 2022. 
 
You asked the Plan to waive the copayment for a magnetic resonance imaging (MRI). You say that in 2021 you 
had a 20% coinsurance for an MRI regardless of if it was in- or out-of-network. You say that it would be less 
expensive for you to go out-of-network for an MRI. The Plan denied your request. The Plan says you have 
been charged the correct copayment 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 $150 
copayment for in-network diagnostic radiology, including magnetic resonance imaging (MRI) and computed 
tomography (CT).  
 
 
 
 You have been asked to pay a $150 copayment for an MRI. The MRI falls 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 the MRI provided on May 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical assistant services provided on February 14, 2022, by 
a Registered Nurse First Assistant (RNFA). 
 
You asked the Plan to pay for the RNFA services. You say that this provider was the only one available to 
perform these services. The Plan denied your request. The Plan says RNFAs are not valid provider types to bill 
for services. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for surgical assistant services provided 
on February 14, 2022, by a Registered Nurse First Assistant (RNFA).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cala Trio nerve stimulation device provided on March 
28, 2022. 
 
You asked the Plan to pay for the Cala Trio nerve stimulation device. You say that the patient has been using 
the device and seeing improvement and control over her hand essential tremor.  You said that this device 
should be covered. The Plan denied your request. The Plan says this device is not covered for the patient's 
condition. 
 
The Plan must follow Medicare rules. Medicare rules say that electrical stimulators to treat motor function 
disorders are not covered.  The Cala Trio device is an electrical stimulator that was provided to the member for 
the sole purpose of treating essential tremor.  Essential tremor is a motor function disorder. We looked at the 
file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Cala 
Trio nerve stimulation device have not been met. Therefore, we decided that the Plan does not have to pay for 
the Cala Trio nerve stimulation device provided on March 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for cardiac rehabilitation on May 16, 2022. 
 
You asked the Plan to waive the copayment for cardiac rehabilitation. You say that you want to appeal the 
amount being charged. The Plan denied your request. The Plan says the cost sharing you are being charged is 
correct. 
 
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 $30 
copayment for cardiac rehabilitation at specialists office. Comprehensive programs of cardiac rehabilitation 
services that include exercise, education, and counseling are covered for members who meet certain conditions 
with a doctor's order. The plan also covers intensive cardiac rehabilitation programs that are typically more 
rigorous or more intense than cardiac rehabilitation programs. The provider billed in the amount of $26.93 and 
the Plan discount is $3.41. $26.93 - $3.41 = $23.52. This is less than the copayment amount. Therefore, results 
in the total cost sharing amount of $23.52. 
 
 
 You have been asked to pay a $23.52 copayment, which is less than the copayment for cardiac rehabilitation. 
Cardiac rehabilitation falls within the cardiac rehabilitation 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 cardiac rehabilitation on May 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tub transfer bench, wheelchair, and commode chair you 
purchased on March 29, 2022. 
 
You asked the Plan to pay for the tub transfer bench, wheelchair, and commode chair. You say that this claim is 
for necessary equipment following knee replacement surgery. The Plan denied your request. The Plan says the 
tub transfer bench is not a covered item. The Plan also states that the commode chair and the wheelchair are not 
covered because you purchased these items.  These items are only covered as rental items. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs (and tub transfer benches) are not 
covered because they are not primarily medical in nature. Medicare rules also state that certain items of durable 
medical equipment must be rented, not purchased. 
 
While a tub transfer bench may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
this item. In addition, the commode chair and the wheelchair you purchased are both considered capped rental 
items.  That means you do not have the option to purchase these items until you have rented the items for at 
least ten months. Therefore, we decided that the Plan does not have to pay for the tub transfer bench, 
wheelchair, and commode chair you purchased on March 29, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) provided on December 23, 2021. 
 
You asked the Plan to pay for the physician service. You say that the service in this case was not related to the 
enrollee's hospice diagnosis. You also say that it should be covered. The Plan denied your request. The Plan 
says the enrollees claim would be covered under Original Medicare as it is responsible for coverage of Part B 
benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan 
also says it is the providers responsibility to verify the enrollees coverage before rendering services and to 
know proper billing procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.   
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the office visit (99214) provided on December 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing panel provided to the enrollee on March 
31, 2022. 
 
You asked the Plan to pay for the genetic testing billed. You say that this should be paid for. The Plan denied 
your request. The Plan says a panel constitutes a single procedural service, so one CPT code must be submitted 
for the panel. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing panel 
provided to the enrollee on March 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 16, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on April 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for a continuous positive airway pressure (CPAP) 
device (E0601) and sales tax (S9999) provided on December 8, 2021. 
 
You asked the Plan to reimburse you for a CPAP device. You say that due to Covid-19 and the shutdown, the 
only CPAP machine available to fit your needs was online. You are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says the item obtained was rendered by a provider who is not 
under contract with the plan and is not certified with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to reimburse you for a continuous positive airway 
pressure (CPAP) device (E0601) and sales tax (S9999) provided on December 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81162, 81201, 81292, 81295, 81298, 81317) 
provided March 27, 2022. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel constitutes a single procedural service, so 
one code must be submitted for the panel. 
 
We looked at the file and Medicare rules. Multiple unbundled codes were submitted for a single testing panel. 
Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. 
Therefore, we decided that the Plan does not have to pay for lab services (81162, 81201, 81292, 81295, 81298, 
81317) provided March 27, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray provided on March 22, 2022. 
 
You asked the Plan to waive the copayment for an x-ray. You say that you should not have to pay this 
copayment. The Plan denied your request. The Plan says the copayment that was applied was correct. 
 
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 X-rays (such as plain film x-rays like a chest x-ray or bone x-ray) in an outpatient hospital.  
 
You have been asked to pay a $50 copayment for an x-ray. An x-ray falls within the Outpatient Diagnostic Test 
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 an x-ray provided on March 22, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray provided on April 14, 2022. 
 
You asked the Plan to waive the copayment for an x-ray. You say that you should not have to pay this 
copayment. The Plan denied your request. The Plan says the copayment that was applied was correct. 
 
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 x-rays (such as plain film x-rays like a chest x-ray or bone x-ray) in an outpatient hospital.  
 
You have been asked to pay a $50 copayment for an x-ray. An x-ray falls within the Outpatient Diagnostic Test 
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 an x-ray provided on April 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on March 16, 2022. 
 
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 these denied codes are inclusive to another code. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 
services at issue in this case were not supported by the medical records. Our physician reviewer found that 
procedure report notes that "bicep tendon was identified and a tenotomy was performed. The tenodesis of the 
biceps was carried out with 0 Vicryl sutures. However, this appears to have been/is an inherent portion of the 
reverse total shoulder. Therefore, the records do not support that CPT 23430- tenodesis of long tendon of 
biceps was a separate and distinct procedure from CPT 23472- arthroplasty, glenohumeral joint, total shoulder 
(glenoid and proximal humeral replacement (e.g., total shoulder)). Additionally, the procedure report notes that 
"attention was then placed to the capsular release. The inferior capsule was clearly identified and dissected. The 
axillary nerve was identified and protected. The capsule was then released and resected." This was performed 
prior to the glenoid preparation for the reverse total shoulder. However, the operative records do not  detail a 
contracted capsule. In addition, the records support that the capsular release was/is inherent in the performance 
of the reverse shoulder arthroplasty. Therefore, there is no apparent record support that the CPT 23020- capsular contracture release was a separate and distinct procedure from CPT 23472- arthroplasty, glenohumeral 
joint, total shoulder (glenoid and proximal humeral replacement (e.g., total shoulder).  
 
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 surgical services provided to the enrollee on March 16, 2022.