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

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on 
December 17, 2021. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you should not be 
responsible for this as you did not call for this service. The Plan denied your request. The Plan says you were 
charged this cost sharing 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 $225 
copayment for each ambulance trip. You had 1 ambulance trip. The Plan charged you $225 for these services. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for the ambulance services provided on December 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 9, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on this date 
of service and attached reports support the level of service. You say that the claim should be reconsidered for 
processing. 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 March 9, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $90 copayment for an emergency room visit on September 
26, 2021. 
 
You asked the Plan to waive the $90 copayment for an emergency room visit. You say that this claim was 
processed incorrectly. The Plan denied your request. The Plan says the cost share has been 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 $90 
copayment for Emergency Care.  
 
You have been asked to pay a $90 copayment for an emergency room visit. An emergency room visit falls 
within the Emergency 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 $90 copayment for an 
emergency room visit on September 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the epoetin alfa injection rendered on December 23, 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 were not billed 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 Q5106 is 60. The MAI value for this code is 2. You billed 70 units of this 
code, exceeding the MUE. 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 epoetin alfa 
injection rendered on December 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an exercise bike (E1399). 
 
You asked the Plan to pre-approve an exercise bike. You say that you have submitted medical records to show 
medical necessity. The Plan denied your request. The Plan says the request is not a covered benefit because the 
home exercise bike is primarily used for a nonmedical purpose and does not meet the definition of DME 
(durable medical equipment). 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an exercise bike (E1399).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit coded 99285 provided on 
February 12, 2022. 
 
You asked the Plan to pay for the emergency department visit. You say that you would like the plan to 
reconsider their 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. 
 
We find that CPT code 99285 is not supported in the medical record. Specifically, this claim is an exact 
duplicate to another claim that was previously submitted for the same date of service. The documentation does 
not support that two emergency department visits were provided on this date of service. This means that this 
claim is a duplicate and cannot be paid as submitted. Based on this information, we decided that Medicare rules 
for coverage of the emergency department visit have not been met. Therefore, we decided that the Plan does 
not have to pay for the emergency department visit coded 99285 provided on February 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on November 5, 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. 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 87150 is culture, typing; identification by nucleic acid 
(DNA or RNA) probe, amplified probe technique, per culture or isolate, each organism probed. The definition 
of code 87801 is infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; amplified 
probe(s) technique. 
 
We find that CPT codes 87150 and 87801 are not supported in the medical record. Specifically, there are no 
laboratory results for these services.  
 
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 codes 
87481, 87640, 87653, and 87798 are column II codes to column I code 87801. 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. 
 
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 laboratory services rendered on November 5, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair lift. 
 
You asked the Plan to pre-approve a wheelchair lift. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a wheelchair lift.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Heart catheterization and Ventriculography (93460) for 
the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that records do not show that the requested service is needed to 
evaluate the enrollee's heart prior to valve surgery. 
 
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 pre-approve these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The patients 
symptoms are not severe enough to warrant valve replacement and the notes indicate plans for continued 
clinical follow-up without plans for valve intervention. Guidelines do not support a need for cardiac 
catheterization in this setting. Our physician reviewer found that the enrollee's condition does not meet criteria 
for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve Heart catheterization and Ventriculography (93460) for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service March 8, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service March 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) test (0037U) provided 
January 24, 2022. 
 
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 does not meet 
Medicare NCD/LCD criteria. 
 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 find that CPT code 0037U is not supported in the medical record. Specifically, 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 January 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics (L1971) for the left foot, provided on March 
17, 2022. 
 
You asked the Plan to pay for foot orthotics. You say that the items at issue were a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for payment for DMEPOS have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the information in 
the enrollees medical record adequately supports the medical necessity for the item. 
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. Specifically, the available medical records do not discuss the items at issue. 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 foot orthotics (L1971) for the left foot, provided on March 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the biopsy, laboratory services, medical 
supplies, CT scan and Part B drugs provided on March 9, 2022. 
 
You asked the Plan to waive the cost share for the biopsy, laboratory services, medical supplies, CT scan and 
Part B drugs. You say that you received multiple bills and you feel that you should only have one bill. The Plan 
denied your request. The Plan says the cost share 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 Part B drugs and medical supplies, a $20 copayment for Medicare-covered laboratory tests, a 
$250 copayment for each Medicare-covered advanced imaging service and a $325 copayment for surgery. 
 
You have been asked to pay a total of $484.96 for the biopsy, laboratory services, medical supplies, CT scan 
and Part B drugs.  
 
Date of Service Service Allowed Amount Cost Share Member Liability 
March 9, 2022 Medical Supplies $209.09 20% coinsurance $41.82 
March 9, 2022 Labs $20 $20 copayment $20 
March 9, 2022 CT Scan $516.90 $250 copayment $103.38 
March 9, 2022 Biopsy $425.70 $325 copayment $305 
March 9, 2022 Part B Drugs $73.80 20% coinsurance $14.76 
Total:    $484.96 
 
The drugs fall within the Medicare Part B Prescription Drugs benefit category. The medical supplies, 
laboratory services and CT scan fall within the Outpatient Diagnostic Tests and Therapeutic Services and 
Supplies benefit category. The biopsy falls within the Outpatient Surgery, Including Services Provided at 
Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the cost share for the biopsy, laboratory services, medical supplies, CT scan and Part B drugs provided 
on March 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 8, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says there is no order 
for these 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 a valid physician order for the 
provided services. 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 
March 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical tooth extraction (D7210) on tooth #30. 
 
You asked the Plan to pre-approve a surgical tooth extraction. You say that this surgery is necessary as your 
tooth is rotting creating a soft bone. You also indicate the tooth is black and creating bacteria growth in your 
mouth. The Plan denied your request. The Plan says the requested service is not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
surgical tooth extraction (D7210) on tooth #30.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0676). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the device is necessary. The 
Plan denied your request. The Plan says the Medicare rules have not been met. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pre-approve a pneumatic compression device (E0676).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Intracept procedure. 
 
You asked the Plan to pre-approve Intracept procedure. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
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 pre-approve Intracept procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has back pain. The Intracept procedure is experimental. More research is 
needed. Therefore, the enrollee does not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Intracept procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Intracept procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 panel coded with codes 81120, 81121, 
81173, 81201, 81210, 81235, 81270, 81272, 81275, 81276, 81293, 81310, 81311, 81314, 81318, 81321, 81400, 
81401, 81402, 81403, 81404, 81405, and 81406 provided on May 10, 2021. 
 
You asked the Plan to pay for the Guardant360 panel. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 81120, 81121, 81173, 81201, 81210, 81235, 81270, 81272, 81275, 81276, 81293, 
81310, 81311, 81314, 81318, 81321, 81400, 81401, 81402, 81403, 81404, 81405, and 81406 are not supported 
in the medical record. Specifically, when a laboratory assays two more genes in an enrollee in parallel, those 
two or more genes will be considered part of the same panel. A panel constitutes a single procedural service so 
only one code should be billed for the panel. Review of the file does not support that only one code was billed 
for the panel provided. Based on this information, we decided that Medicare rules for coverage of the 
Guardant360 panel have not been met. Therefore, we decided that the Plan does not have to pay for the 
Guardant360 panel coded with codes 81120, 81121, 81173, 81201, 81210, 81235, 81270, 81272, 81275, 81276, 81293, 81310, 81311, 81314, 81318, 81321, 81400, 81401, 81402, 81403, 81404, 81405, and 81406 
provided on May 10, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 16, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on the date 
in question. 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 March 16, 2022.