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

 
We decided that the Plan does not have to pay for a Tempus gene panel (81206, 81210, 81235, 81275, 81276, 
81292, 81295, 81298, 81317, 81401, 81301, 81191, 81309) provided on March 14, 2022. 
 
You asked the Plan to pay for a Tempus gene panel. You say that this was medically necessary. The Plan 
denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say that the submission of claims 
using individual gene CPT codes, when either 5-50 or greater than 50 gene panels are ordered, is considered 
incorrect coding. CPT code 81455 should be billed when 51 or greater genes are ordered for molecular 
biomarkers.  
We find that CPT codes 81206, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81317, 81401, 81301, 
81191, and 81309 are not supported in the medical record. Specifically, the record shows that 105 genes were 
tested, which is greater than 51 and should be reported with 81455. Based on this information, we decided that 
Medicare rules for coverage of a Tempus gene panel have not been met. Therefore, we decided that the Plan 
does not have to pay for a Tempus gene panel (81206, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 
81317, 81401, 81301, 81191, 81309) provided on March 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) test (0037U) provided 
August 17, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that the provision of F1CDx to the enrollee meets 
the requirements of the NCD and has been determined by CMS to be reasonable and necessary for the 
management of the enrollee's advanced cancer. The Plan denied your request. The Plan says the services 
rendered were not authorized and therefore not covered by the Plan. 
 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. The next generation sequence testing (NGS) testing panel performed 
included testing for the FANCC gene. Testing for this gene is not a Medicare benefit and is statutorily excluded 
service. In addition to single gene testing, panels that include the FANCC gene are statutorily excluded service. 
Based on this information, we decided that Medicare rules for coverage of the laboratory service have not been 
met. Therefore, we decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) test 
(0037U) provided August 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on November 9, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the documentation 
submitted did not include a lab report or results for the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering 
physicians intent that the tests be performed. 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 the 
lab services provided on November 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99204) provided on February 24, 2022 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. 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 an office visit (99204) provided on February 24, 
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 testing (0047U) provided on August 18, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were not 
billed correctly. 
 The Plan must follow Medicare rules. Medicare rules say that the appropriate claim information must be 
submitted to report a Prostate Genomic Classifier service.  
 
We looked at the file and Medicare rules. The services in question were not billed with an appropriate DEX Z-
Code. The services are not payable as billed. Based on this information, we decided that Medicare rules for 
coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
testing (0047U) provided on August 18, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services provided on December 28, 2021. 
 
You asked the Plan to pay for the emergency room services. You say that the patient advised you that they had 
updated their insurance information, so the Plan should process this claim. The Plan denied your request. The 
Plan says the enrollee had another primary insurer on the date of service in question, so you need to send the 
claim there. 
 
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 advised you 
who the primary insurer is and directed you to bill that insurer.  Records show that the enrollee was active with 
a different primary insurer from September 1, 2021, to January 12, 2022.  The date of service in question falls 
within this timeframe. As the secondary insurer, the Plan cannot be held responsible for the emergency room 
services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan 
does not have to pay for emergency room services provided on December 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) scan of the thorax, with 
contrast material (71260) and a computed tomography (CT) scan of the abdomen and pelvis; with contrast 
material (74177) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a CT scan of the thorax and a CT scan of the abdomen and pelvis. You say 
that you would like to be allowed to have services at the requested facility for the best outcome. The Plan 
denied your request. The Plan says the requested medical group is not contracted with the Plan. There are in-
network providers available in your area to render the requested medical care and services. 
 
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 
computed tomography (CT) scan of the thorax, with contrast material (71260) and a computed tomography 
(CT) scan of the abdomen and pelvis; with contrast material (74177) to be provided by an out-of-network 
(OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies rendered on 
December 28, 2021. 
 
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 must follow Medicare rules. The rules say that only one (1) month, thirty (30) days of the supply 
allowance may be billed to the DME MAC at a time. 
 
We looked at the file and Medicare rules. The file shows that more than 30 days of supply allowance were 
billed. 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 continuous glucose monitor (CGM) 
supplies rendered on December 28, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient admission care services on 
January 10, 2022, to January 11, 2022. 
 
You asked the Plan to waive the copayment for inpatient admission care services. You say that you would like 
to appeal the cost share. 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 $335 
copayment per day, days 1-6: $0 per day, days 7-90 $0 copay for additional days for inpatient admission care 
services.  
 
You have been asked to pay a $335 copayment per day, days 1-6: $0 per day, days 7-90 $0 copay for additional 
days for inpatient admission care services. Inpatient admission care services fall 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 admission care services 
on January 10, 2022, to January 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathology services provided on March 8, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for pathology services. You say that you asked the provider for a referral. You also 
say you used the wrong verbiage. You also say that the correct verbiage should have been to please send prior 
authorization request instead of referral. The Plan denied your request. The Plan says the member was provided 
pathology services with a non-participating provider. The Plan also says that the member was referred to this 
provider by a non-participating provider with the Plan. The Plan also says that they denied the claim for 
payment for lack of authorization with a non-participating provider. 
 
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 pathology services provided on March 8, 2022, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit on February 07, 2022, to April 
01, 2022. 
 
You asked the Plan to waive the copayment for office visit. 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 $15 
copayment for each Medicare-covered primary care doctor visit (including telehealth services and urgently 
needed services). Covered services include medically-necessary medical care or surgery services furnished in a 
physicians office, certified ambulatory surgical center, hospital outpatient department, or any other location 
consultation, diagnosis, and treatment by a specialist. There were 22 visits, resulting in the amount of $330. 
Therefore, results in the total cost sharing amount of $330.  
 
 
 You have been asked to pay a $15 copayment for each 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 February 07, 2022, to April 01, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88342 billed for date of service February 21, 
2022. 
 
You asked the Plan to pay for procedure code 88342. You say that the claim should be paid as billed. The Plan 
denied your request. The Plan says payment for code 88342 is bundled into payment for code 88323.  
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 88342 
is a column II code to column I code 88323. 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 88342 billed for date of service February 21, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the biopsy of prostate and MRI (55899, 52647, 55700, 
77021) provided on November 11, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the MRI. 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 the biopsy of prostate and MRI (55899, 52647, 
55700, 77021) provided on November 11, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on February 2, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 laboratory services provided on February 2, 2022, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (81408, 81407, 891406, 81479) provided 
on December 28, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory 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 laboratory services (81408, 81407, 891406, 
81479) provided on December 28, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on December 24, 2020. 
 
You asked the Plan to pay for the medical services. You say that the facility did not advise you of the enrollee's 
insurance coverage so that you could file timely. The Plan denied your request. The Plan says you did not 
timely file your corrected, final claim. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the medical services was not filed until February 23, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for medical services provided on December 24, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 25, 2022 billed with 
codes 81225, 81227, 81230, 81231, 81232, 81291, 81306, 81355, 81335, 0031U, 0032U, 0033U, 81479, 81407 
and 81238. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says the testing 
was billed incorrectly. 
 
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 
January 25, 2022 billed with codes 81225, 81227, 81230, 81231, 81232, 81291, 81306, 81355, 81335, 0031U, 
0032U, 0033U, 81479, 81407 and 81238.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for opioid treatment services received from January 4, 2022, to 
January 31, 2022. 
 
You asked the Plan to pay for the services. You say that your coverage was in effect for these services. The 
Plan denied your request. The Plan says there is no itemized bill of services. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of opioid treatment services received 
from January 4, 2022, to January 31, 2022 have been met. It is not clear exactly what services were provided in 
this case. The services are unable to be verified as reasonable and necessary. Therefore, we decided that the 
Plan does not have to pay for opioid treatment services received from January 4, 2022, to January 31, 2022.