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

 
We decided that the Plan does not have to pre-approve an air purifier (E1399). 
 
You asked the Plan to pre-approve an air purifier. You say that you have a diagnosis of acute bronchitis. For 
approximately three months, you have a lot of coughing that causes difficulty to breath and catch your breath, 
which is why the equipment was requested. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Specifically, the requested item is not a covered benefit with 
Medicare or your Plan. Based on this information, we decided that Medicare rules for coverage of an air 
purifier have not been met. Therefore, we decided that the Plan does not have to pre-approve an air purifier 
(E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection provided on April 22, 2022. 
 
You asked the Plan to waive the coinsurance for an injection. You say that you dont agree with the 
coinsurance. The Plan denied your request. The Plan says the coinsurance 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 20% 
coinsurance for Medicare covered Part B drugs.  
 
You have been asked to pay .32 cents which is 20% of the allowed amount for an injection. The allowed 
amount is $1.61 (20% x $1.61= .32). Injections fall within the Medicare Part B Prescription Drugs 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 an injection provided on April 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for dialysis provided from January 3, 2022, to 
January 31, 2022. 
 
You asked the Plan to waive the coinsurance for dialysis. You say that you didn't get the services done on 
January 10,2022. The Plan denied your request. The Plan says the coinsurance 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 20% 
coinsurance for Medicare covered renal dialysis.  
 
You have been asked to pay $624 which is 20% of the allowed amount for dialysis. The allowed amount is 
$3,120 (20% x $3,120= $624). Dialysis falls within the Services to Treat Kidney Disease 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 dialysis provided from January 3, 2022, to January 31, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay provided from 
December 29, 2021, to January 20, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you dont agree with the 
cost. 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 $375 
copayment per day for days 1 through 5.  
 
 
 
 You have been asked to pay $1,875 ($375 x 5 days) copayment for inpatient hospital stay. 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 inpatient hospital stay provided from December 29, 2021, to January 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pneumatic compression equipment to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve pneumatic compression equipment. You say that this is medically necessary 
for the enrollee's condition. The Plan denied your request. The Plan says there are multiple in-network 
providers available to provide the care you need. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
pneumatic compression equipment to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management services provided on 
February 15, 2022. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the service is 
included in the primary procedure. 
 
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 99443 is telephone evaluation and management service 
by a physician or other qualified health care professional who may report evaluation and management services 
provided to an established patient, parent, or guardian not originating from a related E/M service provided 
within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest 
available appointment; 21-30 minutes of medical discussion. We find that CPT code 99443 is not supported. The records show that the enrollee received an evaluation and 
management service, on February 8, 202022. This is within the previous 7 days from the date of service at 
issue. Based on this information, we decided that Medicare rules for coverage of the services provided have not 
been met. Therefore, we decided that the Plan does not have to pay for the evaluation and management services 
provided on February 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Cxbladder Detect Test (0012M) provided on March 4, 
2022. 
 
You asked the Plan to pay for a Cxbladder Detect Test. You say that the services were medically necessary. 
The Plan denied your request. The Plan says provider has not submitted any clinical records to support the 
medical necessity of the service(s). 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a Cxbladder Detect Test have not been met. Specifically, medical records were not submitted to 
support the medical necessity of the requested test. Therefore, we decided that the Plan does not have to pay for 
a Cxbladder Detect Test (0012M) provided on March 4, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FoundationOne CDx (F1CDx) testing provided on December 3, 
2021. 
 
You asked the Plan to pay for the F1CDx testing. You say that this is an FDA-approved test eligible for 
Medicare coverage. The Plan denied your request. The Plan says that there is a Local Coverage Determination 
(LCD) that indicates that any panel that tests for the FANCC gene is noncovered. They argue that since this 
panel includes that specific gene, the denial is correct. 
 
We reviewed the LCD cited by the Plan but find that it is not applicable to an FDA-approved test, as these are 
covered via the NCD cited in the Medicare rules section. An LCD cannot limit coverage allowed by an NCD, 
per the Medicare hierarchy of authority. As such, we disregarded the LCD cited by the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, such as the F1CDx panel, when provided for an FDA-approved indication. 
 
We looked at the file and Medicare rules. This testing was provided to a patient with a solid tumor. The FDA 
approval notice indicates that this panel is approved for solid tumors. No other valid denial rationale was 
presented by the Plan. Based on this information, we decided that Medicare rules for coverage of the F1CDx 
testing have been met. Therefore, we decided that the Plan has to pay for the FoundationOne CDx (F1CDx) 
testing provided on December 3, 2021.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 15, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed code 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that 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. The claim in this case was billed with the laboratory POS code. The 
records do not support that the sample was taken in a laboratory setting. 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 provided on November 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation services. 
 
You asked the Plan to pre-approve percutaneous vertebral augmentation services. You say that this procedure 
is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that for percutaneous vertebral augmentation to be 
covered, there must be an osteoporotic vertebral compressive fracture less than 12 weeks old based on 
symptom onset and documented by advanced imaging. 
 
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 pre-approve percutaneous vertebral augmentation 
services. Our reviewer says that the requested procedure is not medically reasonable and necessary based on 
Medicare rules for coverage. Our physician reviewer found there is no documentation that the fracture is less 
than 12 weeks old on imaging or by history as required by Medicare rules. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous vertebral augmentation services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve percutaneous vertebral augmentation services.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the GTC (genomic testing cooperative) Hematology Profile provided 
on August 17, 2021. 
 
You asked the Plan to pay for the GTC Hematology Profile. You say that this test was approved by the MolDX 
program and was medically necessary. The Plan denied your request. The Plan says that there are Medicare 
coverage determinations which indicate that panels including the FANCC and BLM genes are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. Once this is complete, the test is assigned a 
reimbursement rate and a unique test identifier. 
 
We looked at the file and Medicare rules. his test is listed in the DEX database as covered. This determination 
was made and is specific to the test at issue. Though this panel does include genes that another coverage rule 
indicates are non-covered, we find there is no basis to overrule the specific coverage decision made by the 
MolDx contractor for this particular test. Based on this information, we decided that Medicare rules for 
coverage of the GTC Hematology Profile have been met. Therefore, we decided that the Plan has to pay for the 
GTC (genomic testing cooperative) Hematology Profile provided on August 17, 2021.  
 
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 procedure code 99053 billed for date of service January 16, 
2022. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says procedure 
code 99053 is considered bundled and 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 procedure code. 
 
 
 We find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service January 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for podiatry office visit provided on March 23, 
2022. 
 
You asked the Plan to waive the copayment for podiatry office visit. You say that you were not aware of the 
cost. 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 $15 
copayment for each Medicare-covered visit when services are provided by a podiatrist.  
 
You have been asked to pay $15 copayment for podiatry office visit. Podiatry office visits fall within the 
Podiatry 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 podiatry office visit 
provided on March 23, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the next generation sequencing provided on May 26, 2021. 
 
You asked the Plan to pay for the testing services. You say that the testing plays an important role in making a 
definitive diagnosis. The Plan denied your request. The Plan says that the testing is not a covered benefit. 
 
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. 
 
We looked at the file and the rules. The testing in this case was provided to the enrollee with a solid tumor. The 
MolDX team has determined that this panel is approved for solid tumors. No other valid denial rationale was 
presented by the Plan. The Plan has not made reasonable and diligent efforts to gather and forward to us 
information regarding their decision to deny your request.  Therefore, we decided that the Plan has to pay for 
the next generation sequencing provided on May 26, 2021.  
 
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 copayments for podiatry office visit, diagnostic ultrasound 
and x-ray provided on March 10, 2022. 
 
You asked the Plan to waive the copayments for podiatry office visit, diagnostic ultrasound, and x-ray. You say 
that you dont agree with the cost. The Plan denied your request. The Plan says the copayments applied are 
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 $10 
copayment for diagnostic ultrasounds and x-rays as well as a $15 copayment for each podiatry office visit.  
 
You have been asked to pay a total of $35 copayment for podiatry office visit, diagnostic ultrasound, and x-
ray., Diagnostic ultrasound and x-rays fall within the Outpatient Diagnostic Tests and Therapeutic Services 
and Supplies benefit category. Podiatry office visits fall within the Podiatry 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 copayments for podiatry office visit, diagnostic ultrasound and x-ray 
provided on March 10, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic colonoscopy provided on April 
18, 2022. 
 
You asked the Plan to waive the copayment for diagnostic colonoscopy. You say that you thought insurance 
covered this you were not aware if a polyp was found the cost could change. 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 $350 
copayment per visit, per provider, per day for surgery performed in an outpatient hospital setting.  
 
 You have been asked to pay $350 copayment for diagnostic colonoscopy. Diagnostic colonoscopys fall 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 diagnostic colonoscopy 
provided on April 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for specialist office visit provided on February 
11, 2022. 
 
You asked the Plan to waive the deductible for specialist office visit. You say that you should only have a $50 
copayment. The Plan denied your request. The Plan says the deductible applied is correct. 
 
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 $233 deductible which applies to Physician/Practitioner Services, 
Including Doctor's Office Visits.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category 
Physician/Practitioner Services, Including Doctor's Office Visits. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is $233 deductible which applies to Physician/Practitioner Services, 
Including Doctor's Office Visits. This cost sharing is a contractual obligation that had not been met at the time 
specialist office visit was received on February 11, 2022. Therefore, we decided that the Plan does not have to 
waive the deductible for specialist office visit provided on February 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CX bladder test provided on February 15, 2022. 
 
You asked the Plan to pay for the CX bladder test (requested under code 0012M). You say that the testing is 
medically necessary to treat the enrollee. The Plan denied your request. The Plan says they reaffirmed non-
coverage for the CX bladder testing. 
 
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 CX bladder test (requested under code 
0012M). Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that the CX bladder test is not considered a screening test 
for urothelial cancer. Cystoscopy, ureteroscopy, possible biopsy and upper tract imaging will still be necessary 
regardless of the results of CX bladder testing. Urinary biomarker tests such as CX Bladder give significant 
false-negative results in patients with urothelial cancer and are subject to false-positive results in others. 
Accuracy is poor for low-stage and low-grade tumors. 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CX bladder test (requested under code 0012M) have not been met. Therefore, 
we decided that the Plan does not have to pay for the CX bladder test provided on February 15, 2022.