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

 
We decided that the Plan does not have to pay for the fluoroscopic guidance for central venous access device 
placement, replacement or removal (77001), insertion of tunneled centrally inserted central venous catheter 
(36558), and ultrasound guidance for vascular access (73693) provided on April 11, 2022. 
 
You asked the Plan to pay for the physician services. You say that the services should be covered. The Plan 
denied your request. The Plan says the claim denied correctly. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has tried to 
obtain the Evidence of Benefits from the primary plan. As the secondary insurer, the Plan cannot be held 
responsible for the physician services until the primary insurer has denied the claim for these services. 
Therefore, we decided that the Plan does not have to pay for the fluoroscopic guidance for central venous 
access device placement, replacement or removal (77001), insertion of tunneled centrally inserted central 
venous catheter (36558), and ultrasound guidance for vascular access (73693) provided on April 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided April 21, 2022. 
 
You asked the Plan to pay for the orthosis. You say that please reconsider the denial and find attached the 
detailed written order and medical record for the enrollee. The Plan denied your request. The Plan says services 
not documented in the enrollee's medical records. 
 
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 physician order, proof of delivery, or relevant medical records which 
support medical necessity for the supplies provided in this case. Specifically, there is no claim in the enrollee's 
history from the prescribing provider on the date of service or in the last 6 months prior to the date of service, 
no legible hand signed order or prescription for the device and no delivery confirmation.  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 the lumbar-sacral orthosis (L0650) provided April 
21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 21, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the lab services. You say that you provided necessary services as ordered by the 
referring physician. The Plan denied your request. The Plan says these services are not covered when provided 
OON. 
 
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 the lab services provided on January 21, 2022, by 
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the glucose assay coded 82947 provided on February 26, 
2021. 
 
You asked the Plan to pay for the glucose assay. You say that you disagree with the Plan's 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. 
 
In this case, the CPT Code Manual definition of code 82947 is glucose; quantitative, blood (except reagent 
strip). 
 
 
 We find that CPT code 82947 is not supported in the medical record. Specifically, the documentation shows 
that the enrollee had a metabolic panel provided on this date of service. This means there is a more appropriate 
code to describe the services rendered. Based on this information, we decided that Medicare rules for coverage 
of the glucose assay have not been met. Therefore, we decided that the Plan does not have to pay for the 
glucose assay coded 82947 provided on February 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient specialist office visit provided 
on November 2, 2021. 
 
You asked the Plan to waive the copayment for an outpatient specialist office visit. You say that you shouldn't 
be responsible for the copayment because all copayments were being waived due to Covid-19 during that time. 
The Plan denied your request. The Plan says the copayment applied 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 $40 
copayment for in-network specialist office visit.  
 
You have been asked to pay a $40 copayment for an outpatient specialist office visit. An outpatient specialist 
office visit falls within the Physician/Practitioner services, Including Doctor's Office Visits benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for an outpatient specialist office visit provided on November 2, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 3, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, a genetic hereditary predictive screening, was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the laboratory services rendered on January 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing rendered on December 17, 2021, 
and January 17, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the testing is not covered. 
 
The Plan must follow Medicare rules. The rules say that next generation sequencing (NGS) is covered when 
the beneficiary has not been previously tested with the same test using NGS for the same cancer genetic 
content. 
 
We looked at the file and Medicare rules. The file shows that the enrollee previously received this testing for 
the same cancer genetic content. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 
testing rendered on December 17, 2021, and January 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0180 billed for date of service March 29, 
2022. 
 You asked the Plan to pay for procedure code G0180. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says payment for code G0180 is bundled into 
payment for code 99336. 
 
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, we have confirmed that code G0180 
is a column II code to column I code 99336. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code G0180 billed for date of service March 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71260 billed for date of service May 4, 2022. 
 
You asked the Plan to pay for procedure code 71260. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 71260 is bundled into payment for 
code 71275.  
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, we have confirmed that code 71260 
is a column II code to column I code 71275. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 71260 billed for date of service May 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services provided on May 31, 2022 to June 
18, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered 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 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 the chiropractic services provided on May 31, 
2022 to June 18, 2022 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient surgery services provided on November 30, 2021 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient surgery services. You say that these services were provided in 
good faith and lack of preauthorization should not preclude payment. The Plan denied your request. The Plan 
says unauthorized, non-plan care is not covered. 
 
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 
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 outpatient surgery services provided on November 
30, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 12, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says payment for code 70450 is bundled into 
payment for code 70496. 
 
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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Guardant250 CDx genetic test (0242U) billed for date of 
service March 22, 2022. 
 
You asked the Plan to pay for genetic testing. You say that the service at issue was a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for payment have not been met because the service 
at issue has been billed with the incorrect DOS. 
 
The Plan must follow Medicare rules. Medicare rules say that the DOS of the test/service must be the date the 
specimen was collected. 
 
We looked at the file and Medicare rules. In this case, the available records document that the specimen was 
collected on March 17, 2022. The service at issue was billed with the incorrect DOS. Based on this 
information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we 
decided that the Plan does not have to pay for a Guardant250 CDx genetic test (0242U) billed for date of 
service March 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-Melamona test rendered to the enrollee on 
May 9, 2022. 
 
You asked the Plan to pay for the test. You say that this is not covered Medicare benefit. The Plan denied your 
request. The Plan says the date of service for a clinical laboratory test or the technical component of physician 
pathology service must be the date the specimen was collected. 
 
The Plan must follow Medicare rules. Medicare rules say that as a general rule, the date of service for clinical 
laboratory tests must be the date that the specimen was collected. 
 
In most normal situations, the date of service for laboratory service is the date that specimen was collected, not 
the date that the specimen was collected. There is an exception if the test is an Advanced Diagnostic Lab Test 
(ADLT), and the specimen was collected from a hospital outpatient during an encounter. The DecisionDX-
Melanoma test is an ADLT; however, the enrollee was not a hospital outpatient when the specimen was 
collected. Based on this information, we decided that Medicare rules for coverage of the test have not been met. 
Therefore, we decided that the Plan does not have to pay for the DecisionDx-Melamona test rendered to the 
enrollee on May 9, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for drug testing (G0483) billed for date of service April 27, 2022. 
 
You asked the Plan to pay for drug testing. You say that you have provided medical records to support the 
services billed. The Plan denied your request. The Plan says that rules for payment have not been met because 
the case record does not contain a physician order for the services at issue. 
 
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. Specifically, the Plan indicates that the physician order submitted does not 
match the enrollee's name on the claim form. The Plan did not provide us with a copy of the defective 
physician order. It is the Plan's responsibility to substantiate its denial with evidence. In this case, the denial has 
not been substantiated, so we must find in your favor. Therefore, we decided that the Plan has to pay for drug 
testing (G0483) billed for date of service April 27, 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 reduce the copayment for a specialist visit on May 2, 2022. 
 
You asked the Plan to reduce the copayment for a specialist visit. You say that the copayment should be $30. 
The Plan denied your request. The Plan says that the cost share 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 $43 
copayment for services received from specialists that are not Level 1 specialists.  
 
 
 
 
 
 
 
 You have been asked to pay $43 for a specialist visit. A specialist visit falls within the Physician/Practitioner 
Services, Including Doctors 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 reduce the copayment 
for a specialist visit on May 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory work provided on February 7, 2022, by an out-
of-network (OON) provider. 
 
 
 You asked the Plan to pay for the laboratory work. You say that the service was medically necessary, and it is 
not standard for a freestanding laboratory to request prior authorization. The Plan denied your request. The 
Plan says no prior authorization was 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 did not pre-approve the 
laboratory work. We found no exception that would require the Plan to pay for the laboratory work. Therefore, 
we decided that the Plan does not have to pay for the laboratory work provided on February 7, 2022, by an out-
of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the manual therapy techniques (97140) provided on May 27, 
2022. 
 
You asked the Plan to pay for the outpatient physical therapy service. You say that this should be processed 
and paid as an out-of-network claim. The Plan denied your request. The Plan says the claim denied correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that payment will be made for outpatient 
rehabilitation therapy services only when they are provided by those trained specifically in physical therapy, 
occupational therapy or speech-language pathology. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the outpatient physical therapy service have not been met. Specifically, the file does not indicate 
that the provider in this case is specifically trained in physical therapy, occupational therapy or speech-
language pathology. Therefore, we decided that the Plan does not have to pay for the manual therapy 
techniques (97140) provided on May 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder test provided to the enrollee on March 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 this test is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that the current literature does not support the use of 
the CxBladder detect test. 
 
The denied test is not a covered benefit at this time. 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 the 
CxBladder test provided to the enrollee on March 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 12 pack of laser treatments purchased on May 4, 2022. 
 
You asked the Plan to pay for the 12 pack of laser treatments. You say that you believe the laser treatments 
should be covered under your reimbursement benefit because it has been offered to you in addition to your 
physical therapy treatments. The Plan denied your request. The Plan says the 12 pack of laser treatments is not 
eligible for coverage under your reimbursement program. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items. However, your 
plan offers a supplemental benefit for specific OTC items. Laser treatments are not listed as a covered OTC 
benefit under the supplemental reimbursement program. Therefore, we decided that the Plan does not have to 
pay for the 12 pack of laser treatments purchased on May 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the podiatry services provided on April 6, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for these services. You say that authorization was not previously required. The Plan 
denied your request. The Plan says the services were rendered 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 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 the podiatry services provided on April 6, 2022 by 
an out-of-network (OON) provider.