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

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on November 2, 
2021. 
 
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 services are not covered because this is not deemed a medical necessity by the payer. 
 
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 that Tempus Gene Panel testing is not sufficiently supported by published medical literature. Tempus 
Gene Panel testing has not been Food and Drug Administration (FDA)-approved, and there is insufficient 
documentation of analytical validity and clinical utility. The Tempus Gene Panel is a panel of over 648 genes, 
which would reasonably exceed the enrollee's medical need. It has not been demonstrated that the Tempus 
Gene Panel is at least as beneficial as existing and available medically appropriate alternatives. 
 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 provided to the enrollee on November 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on January 11, 
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 this was not reported correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 In this case, the MUE for CPT code 88291 is 1. You billed 2 units of this code, exceeding the MUE. The 
records do not contain any supporting information showing support for additional billing of CPT 88291. 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 provided to the enrollee on January 11, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a blood smear (85060) provided to the enrollee on January 
10, 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 no payment is recognized for code 85060 furnished to hospital outpatients or non-hospital 
patients. 
 
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 85060 is "Blood smear, peripheral, interpretation by 
physician with written report." 
 
We find that CPT code 85060 is not supported in the medical record. Specifically, the claim was billed with a 
place of service of 22 for outpatient hospital. This code is not appropriate to bill for hospital outpatients. 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 a blood smear (85060) provided to the enrollee on January 
10, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for trauma response services provided to the enrollee from 
November 19, 2021, to November 22, 2021. 
 
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 critical care services with trauma activation were reported using HCPCS code G0390 without 
CPT code 99291. 
 
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 Healthcare Common Procedure Coding System code G0390 is 
"Trauma response team associated with hospital critical care service." 
 
We asked our coder 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 reviewer found that in this case, the services were 
incorrectly reported without CPT 99291. 
 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 trauma response services provided to the enrollee from November 19, 2021, to November 22, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CancerTYPE ID test provided to the enrollee on August 
3, 2021. 
 
You asked the Plan to pay for the testing. You say that many payers cover this testing. The Plan denied your 
request. The Plan says this test has not been cleared or approved by the Food and Drug Administration (FDA). 
 
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 testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this testing has not cleared or approved by the Food and Drug Administration. There is insufficient 
evidence that this testing is medically reasonable and necessary, meets but does not exceed the enrollee's 
medical need, and is at least as beneficial as existing and available medically appropriate alternatives. 
 
 
 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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the CancerTYPE ID test provided to the enrollee on August 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiation therapy services provided on January 5 to January 
18, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for radiation therapy services. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for out-of-network 
care have not been met. 
 
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 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 radiation therapy 
services provided on January 5 to January 18, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to reduce the copayment for an ultrasound. We decided that the Plan does not 
have to waive the copayment for an ultrasound.  
 
You asked the Plan to waive the copayment for an ultrasound. You say that you were charged a copayment for 
your surgery. You feel that you should not also be charged for the ultrasound performed during this surgery. 
The Plan says that the copayment applied was correct. 
 
 
 We decided that the Plan has to reduce the copayment for an ultrasound.  
 
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 other in-network outpatient diagnostic tests.  
 
The Plan says you must pay a $100 copayment for an ultrasound. Based on the Plan contract, however, you 
cannot be asked to pay more than a $10 copayment for an ultrasound. Therefore, we decided that the Plan has 
to reduce the copayment for an ultrasound.  
 
We also decided that the Plan does not have to waive the copayment for an ultrasound. 
 
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 an ultrasound. Therefore, we decided that the Plan does not have to waive the copayment for an 
ultrasound. 
 
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 pay for additional imaging services provided to the enrollee on July 
3, 2021. 
 
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 records submitted do not indicate that two separate services were performed/supported 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
 We find that the records do not support that two computed tomography (CT) scans were rendered in this case. 
The denied claim is a duplicate. 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 additional imaging 
services provided to the enrollee on July 3, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the chiropractic manipulation of the extremity (code 98943) you 
received on February 2, 2022. 
 
You asked the Plan to pay for the chiropractic manipulation of the extremity. You say that this is a legal and 
covered procedure under your plan. The Plan denied your request. The Plan says that your plan only covers 
manual manipulation of the spine. 
 
Medicare generally only pays for manual manipulation of the spine provided by a chiropractor.  However, 
according to your Evidence of Coverage, your Plan offers a supplemental chiropractic benefit.  Under this 
benefit, there is explicit coverage for chiropractic manipulation of the extremities, which is the exact service 
you received. The Plan has provided no evidence that you would not qualify for this supplemental benefit.  
This means that this service is a covered supplemental benefit under your Plan to which you are entitled. Based 
on this information, we decided that Medicare rules for coverage of the chiropractic manipulation of the 
extremity have been met. Therefore, we decided that the Plan has to pay for the chiropractic manipulation of 
the extremity (code 98943) you received on February 2, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections and acupuncture services (20553, 97813) provided 
on September 1, 2021, to December 22, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the injections and acupuncture services. You say that the services should be 
covered as you disagree with the denial. The Plan denied your request. The Plan says the services denied 
correctly as they were non-emergent and prior authorization was not obtained. 
 
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 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 injections and acupuncture services (20553, 
97813) provided on September 1, 2021, to December 22, 2021 by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the various services provided to the enrollee from February 
16, 2021, to February 18, 2021. 
 
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 services should be billed under Original Medicare. 
 
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 various services provided to the enrollee from February 
16, 2021, to February 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on February 8, 
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 in addition to single gene testing, panels that include the FANCC gene are statutorily excluded 
service. 
 
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 MolDX Team has determined that testing for the FANCC is not a Medicare benefit and is a 
statutorily excluded service. In addition to single gene testing, MolDX will also deny panels of tests that 
include the FANCC gene. The case file does not contain documentation that demonstrates that the enrollee in 
this case has not been previously tested with the same test using NGS for the same cancer genetic content and 
has decided to seek further cancer treatment (e.g., therapeutic chemotherapy). There is no clinical 
documentation that supports that the criteria listed in the NCD were satisfied for the ordered testing, including 
support that it would be used in enrollee's treatment options. 
 
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 provided to the enrollee on February 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on January 12, 
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 Current Procedural Terminology (CPT) code 20611 LT (2 units) remains not supported. 
 
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 20611 is "Arthrocentesis, aspiration and/or injection, 
major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent 
recording and reporting." 
 
We asked our coder 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 reviewer found a single unit of CPT 20611 should be reported for each joint treated, regardless of how 
many aspirations and/or injections occur in a single joint. You may report multiple units of a single code for 
aspiration/injection of multiple joints of same size. (e.g., two large joints, left knee and left shoulder). If 
aspirations and/or injections occur on opposite, paired joints (e.g., both knees), report one unit of 20610 with 
modifier 50 Bilateral procedure appended, per Centers for Medicare & Medicaid (CMS) instruction. 
 
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 surgical services provided to the enrollee on January 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 10, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you submitted documentation for review. The Plan 
denied your request. The Plan says the rendering provider is an OON provider and there was no referral from 
an in-network provider or an approved authorization. Also, the service rendered was not urgent 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 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 an office visit provided on February 10, 2022, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to reduce the copayment for the chemotherapy administration. We decided that 
the Plan does not have to fully waive the coinsurance for the daratumumab injection and chemotherapy 
administration.  
 
You asked the Plan to reduce the copayment for the injection and chemotherapy. You say that the services were 
covered previously. The Plan says that the correct coinsurance and copayment were applied. 
 
We decided that the Plan has to reduce the copayment for the chemotherapy administration.  
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for therapeutic radiology services. 
 
The Plan says that you must pay $62.37, which is less than the $195 copayment for the outpatient visit. Based 
on the Plan contract, however, you cannot be asked to pay more than a 20% coinsurance for therapeutic 
radiology services, which would be $12.47 ($62.37 allowed amount x 20% coinsurance = $12.47). Therefore, 
we decided that the Plan has to reduce the $62.37 copayment for the chemotherapy administration to $12.47. 
 
We also decided that the Plan does not have to waive the copayment for the daratumumab injection. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for chemotherapy drugs. 
 
You have been asked to pay $1,702.29, which is 20% of the allowed amount for the injection ($8,511.43 
allowed amount x 20% coinsurance = $1,702.29). The injection falls within the Outpatient Hospital Services 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the coinsurance for the daratumumab injection. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the power wheelchair you purchased on November 9, 2021. 
 
You asked the Plan to pay for the power wheelchair. You say that you have multiple sclerosis and needed this 
chair. The Plan denied your request. The Plan says there are no medical records to support the necessity of this 
item. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that despite multiple requests by the Plan, no medical records have been provided by the non-
plan durable medical equipment vendor from whom you purchased this electric wheelchair that would support 
that you have a mobility deficit that impairs your participation in MRADLs or that your condition cannot be 
improved by a walker, cane, or manual wheelchair. Without such records, the Plan cannot determine if you 
meet medical necessity criteria for this item.  This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan 
does not have to pay for the power wheelchair you purchased on November 9, 2021.