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

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on December 8, 2021. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
December 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an oxygen concentrator provided on April 
23, 2021. 
 
You asked the Plan to waive the coinsurance for an oxygen concentrator. You say that you were not aware 
there was a coinsurance charge for this durable medical equipment (DME). The Plan denied your request. The 
Plan says the coinsurance applied was 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 20% 
coinsurance for durable medical equipment (DME). The allowed amount of this item is $146.05 resulting in a 
coinsurance amount of $29.21 ($146.05 x 20% = $29.21). 
 
You have been asked to pay a $29.21 coinsurance for an oxygen concentrator. an oxygen concentrator falls 
within the durable medical equipment (DME) and related supplies 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 oxygen concentrator provided on April 23, 2021.   
Your complaint about not being aware of your cost share is not a valid appeal for medical coverage. This part 
of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opdivo. 
 
You asked the Plan to pre-approve Opdivo. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Opdivo. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found single agent use is not considered a 
standard of care and not supported by the NCCN Guidelines, major drug compendia, or the medical literature 
as first line systemic therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Opdivo have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Opdivo.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for magnetic resonance angiography (MRA) of the head provided to the 
enrollee on September 28, 2021. 
 
You asked the Plan to pay for the services. You say that this should be considered for separate reimbursement, 
and not bundled under payment for the procedure. The Plan denied your request. The Plan says that the denied 
code remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code 70544 is "Magnetic resonance angiography, head; without contrast material(s)." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the provider performed an MRA 
(blood vessels) and an MRI (organs and tissues) with a full report of both procedures. The provider reported 
services with modifier -59, which was appropriate. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
magnetic resonance angiography (MRA) of the head provided to the enrollee on September 28, 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 the laboratory services related to end-stage renal disease 
(ESRD) provided on November 10, 2021. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these services were 
medically necessary. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-
related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
November 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oxygen concentrator (E1390) provided September 22, 
2020. 
 
You asked the Plan to pay for the oxygen concentrator. You say that this device was medically necessary. The 
Plan denied your request. The Plan says only rented oxygen equipment is eligible for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that only rented oxygen equipment is eligible for 
coverage. Purchased oxygen equipment is statutorily non-covered. 
 
We looked at the file and Medicare rules. The oxygen concentrator was purchased. Based on this information, 
we decided that Medicare rules for coverage of the oxygen concentrator have not been met. Therefore, we 
decided that the Plan does not have to pay for an oxygen concentrator (E1390) provided September 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a walker (E0149) provided on February 20, 2022. 
 
You asked the Plan to pay for the walker. You say that the walker was medically necessary. The Plan denied 
your request. The Plan says this item was obtained from an out-of-network 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 at issue in this appeal. The Plan did not pre-approve the item at 
issue. We found no exception that would require the Plan to pay for these items. Therefore, we decided that the 
Plan does not have to pay for a walker (E0149) provided on February 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a left heart catheterization including intraprocedural 
injection(s) for left ventriculography, imaging supervision and interpretation, when performed (93452) and a 
catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for 
coronary angiography, imaging supervision and interpretation (93454). 
 
You asked the Plan to pre-approve cardiac catheterization. You say that the left heart catherization components 
are medically necessary. The Plan denied your request. The Plan says the request cannot be approved because 
more than one detailed picture study for the same condition was requested at the same time. 
 
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 cardiac catheterization. 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 not had evidence of chest pain or other possible cardiac symptoms. 
Guidelines do not support a need for cardiac catheterization in this setting. As a result, at this time cardiac 
catheterization would not be considered medically appropriate and necessary in the enrollees clinical 
management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cardiac catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a left heart catheterization including intraprocedural injection(s) for left 
ventriculography, imaging supervision and interpretation, when performed (93452) and a catheter placement in 
coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, 
imaging supervision and interpretation (93454).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for genetic testing (0037U) provided January 12, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary and is a 
covered service. The Plan denied your request. The Plan says that testing panels that include the FANCC gene 
are non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers Next Generation 
Sequencing (NGS) as a diagnostic laboratory test when the test has Food & Drug Administration (FDA) 
approval. 
 
We looked at the file and Medicare rules. The plan has cited Local Coverage Article: Billing and Coding: 
MolDX: FANCC Genetic Testing (A53628) as the basis for it's denial of this genetic testing panel. Under the 
National Coverage Determination, this panel is covered as it is FDA approved for the enrollee's condition. 
Based on this information, we decided that Medicare rules for coverage of the genetic testing have been met. 
Therefore, we decided that the Plan has to pay for genetic testing (0037U) provided January 12, 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a duplex scan (ultrasound) of extracranial 
arteries provided on March 30, 2022. 
 
You asked the Plan to reduce the copayment for the ultrasound. You say that you should only have a $100 
copayment for advanced imaging services. The Plan denied your request. The Plan says you have been charged 
the correct cost sharing amount. 
 
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 $125 
copayment for diagnostic procedures and tests, including ultrasounds.  
 
You have been asked to pay a $125 copayment for the ultrasound. The ultrasound falls within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies 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 duplex scan (ultrasound) of extracranial arteries provided on March 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on January 19, 2022. 
 You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says there were no medical/doctor notes 
given with this appeal that show the clinical rationale in ordering these tests. 
 
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. In this case, no medical records were provided from the ordering 
provider indicating why the testing was ordered or why it would assist in the clinical management of the 
enrollees condition. Based on this information, we decided that Medicare rules for coverage of the genetic 
testing services have not been met. Therefore, we decided that the Plan does not have to pay for the genetic 
testing services provided on January 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve maxillary partial dentures (D5225) and mandibular 
partial dentures (D5226). 
 
You asked the Plan to pre-approve the dental services. You say that you need new dentures, and it is painful to 
eat without them. The Plan denied your request. The Plan says your benefit for the requested items or services 
has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested items or services was exhausted on date of service April 6, 2021. 
Therefore, we decided that the Plan does not have to pre-approve maxillary partial dentures (D5225) and 
mandibular partial dentures (D5226).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to further pay for the chemotherapy and related services provided from 
February 4, 2022, through April 15, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to further pay for the chemotherapy and related services. You say that you were told that 
you would be fully covered after a maximum of $3400. The Plan denied your request. The Plan says although 
the Plan covers services provided by an OON provider, there is a $5,000 benefit limit. 
 
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 after the point-of-
service benefit annual limit of $5,000 has been exhausted, the costs are the responsibility of the member. 
 
In this case, the Plan has met its contractual obligation to provide a benefit of $5,000 for services received 
using the OON point-of-service benefit. This means that you have been asked to pay the correct amount for 
additional care beyond this $5,000 annual limit 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 further pay for the chemotherapy and related services provided from February 4, 2022, 
through April 15, 2022, by an out-of-network (OON) provider.  
 
Your complaint about receiving incorrect information about services being covered is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81206, 81210, 81235, 
81272, 81275, 81276, 81292, 81301, 81311, 81321) provided on February 21, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered 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. 
 
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. Correct coding requires that when a panel code is ordered, it should be 
billed, rather than the individual gene codes. Therefore, we decided that the Plan does not have to pay for the 
laboratory services (CPT code(s): 81206, 81210, 81235, 81272, 81275, 81276, 81292, 81301, 81311, 81321) 
provided on February 21, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for mammography on March 16, 2022. 
 
You asked the Plan to waive the cost share for mammography. 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 there is no coinsurance 
or copayment for covered screening mammograms. Covered services include: one baseline mammogram 
between the ages of 35 and 39, one screening mammogram every 12 months for women aged 40 and older, and 
clinical breast exams once every 24 months. The provider billed in the amount of $148 and $128. $148 + $128 
= $276. Therefore, results in the total cost sharing amount of $276.  
 
You have been asked to pay the cost sharing amount of $276 for mammography. Mammography falls within 
the Breast cancer screening (mammograms) 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 mammography on March 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for magnesium testing provided to the enrollee on March 5, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for a diagnosis of multiple 
myeloma, not having achieved remission. The Plan denied your request. The Plan says none of the covered 
symptoms were documented in the submitted records. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that  Our 
physician reviewer found that the enrollee was on oral magnesium chloride-calcium carbonate, and magnesium 
hydroxide suspension as needed for constipation. The enrollee underwent laboratory testing for magnesium. 
The clinical documentation is limited. There is no rationale provided as to why the enrollee required a 
magnesium level. The documentation does not support that the service is medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for magnesium testing provided to the enrollee on March 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for portable oxygen equipment provided on 
March 23, 2021. 
 
You asked the Plan to waive the coinsurance for the portable oxygen equipment. You say that you were not 
informed of any monthly costs for the equipment. The Plan denied your request. The Plan says the correct 
coinsurance was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for durable medical equipment (DME) items, including oxygen equipment.  
 
Item Allowed Amount 20% Coinsurance 
Oxygen Concentrator $123.75 $24.75 
Portable Oxygen Machine $22.30 $4.46 
Total:  $29.21 
 
You have been asked to pay a total of $29.21, which is 20% of the allowed amount for the portable oxygen 
equipment. The portable oxygen equipment falls within the Durable Medical Equipment (DME) and Related 
Supplies 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 portable oxygen 
equipment provided on March 23, 2021.