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

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on February 26, 2021. 
 
You asked the Plan to pay for the testing services. You say that the test was ordered to determine if there was a 
more effective therapy to treat the enrollee's advanced cancer. The Plan denied your request. The Plan says the 
testing should be reported with CPT 81479. 
 
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 looked at the file and the rules. The claim information shows that the testing panel was billed with multiple 
codes. If a single procedure is performed, only one code with one unit of service may be reported for the 
procedure. In this case, the billing criteria shows code 81479 should be reported. Based on this information, we 
decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that 
the Plan does not have to pay for the Guardant360 testing provided on February 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for removal of torus mandibularis with anesthesia provided by 
an out-of-network provider on February 15, 2022. 
 
You asked the Plan to pay for dental services. You say that this needed to be done. The Plan denied your 
request. The Plan says the denial of payment for these services is correct, because out-of-network dental 
services are not covered. 
 
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 when performed by an out-of-network dentist. Therefore, we decided 
that the Plan does not have to pay for removal of torus mandibularis with anesthesia provided by an out-of-
network provider on February 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says there is 
no medical indication for the testing for dementia patients. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
The file shows that Interleukin-6 (IL-6) and DNA sequencing were requested. 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 the requested services. Our physician reviewer found that in this 
case the enrollee has been diagnosed with advanced Lewy Body Dementia (LBD). There was no mention in the 
records of why IL-6 testing is sought or what kind of DNA sequencing is sought. Nonetheless, LBD is a 
diagnosis that is generally made on a clinical basis. It does not require genetic confirmation. Performance of 
IL-6 testing in LBD (and Alzheimer's) at this time is most done in the academic/research setting. In as much 
this service would not meet the Medicare definition of medical necessity. Likewise, genetic evaluation is not 
otherwise required in the evaluation of dementia. Its use is largely investigational. Given this limitation, this 
type of test is also not consistent with standards of care. Therefore, it would not be medically 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genetic testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment provided on January 5, 2022. 
 
You asked the Plan to pay for the services provided. You say that the walker was purchased to keep the 
enrollee from falling again. The Plan denied your request. The Plan says the provider is not certified with 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
We looked at the file and the rules. The records indicate that the provider at issue is not enrolled in the 
Medicare program. Therefore, we decided that the Plan does not have to pay for the durable medical equipment 
provided on January 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and panoramic x-
rays (D0330) provided on June 8, 2020, and extractions (D7140 x 10) provided on June 18, 2020. 
 
You asked the Plan to pay for the dental services. You say that you were told on multiple visits that the services 
were covered. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental benefits. 
 
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. 
 
 The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a comprehensive oral evaluation (D0150) and panoramic x-rays (D0330) provided on June 8, 2020, 
and extractions (D7140 x 10) provided on June 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and periapical x-rays 
(D0220) provided on January 25, 2022, and an extraction of tooth #15 (D7140) provided on February 1, 2022. 
 
You asked the Plan to pay for an evaluation. You say that you disagree with the denial of dental services. The 
Plan denied your request. The Plan says a limited oral evaluation (D0140) is not covered by your supplemental 
dental benefits. 
 
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 pay for a limited 
oral evaluation (D0140) and periapical x-rays (D0220) provided on January 25, 2022, and an extraction of 
tooth #15 (D7140) provided on February 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910), oral exam (D0120), 
and bitewing x-rays (D0274) provided on November 2, 2021. 
 
You asked the Plan to pay for the dental services. You say that you did not know your new plan had dental 
coverage. You say that after your appointment, you discovered that you did. You say that you did not know 
that you had to use an approved dentist. You also say that you would like this to be covered as a one-time 
exception. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the oral exam and bitewing x-rays are not covered 
under this benefit when received from an out-of-network provider. Additionally, periodontal maintenance is not listed 
as a covered service regardless of the provider's network status. Therefore, we decided that the Plan does not 
have to pay for the periodontal maintenance (D4910), oral exam (D0120), and bitewing x-rays (D0274) 
provided on November 2, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on December 19, 2021. 
 
You asked the Plan to pay for the testing services. You say that the results aided in the care of the enrollee. The 
Plan denied your request. The Plan says the place of service is not appropriate for the code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
In this case, the CPT Code Manual definition of code 85060 is blood smear, peripheral, interpretation by 
physician with written report. We find that CPT code 85060 was billed with a place of service 23, emergency room of a hospital. No payment 
is recognized for code 85060 furnished to hospital outpatients or non-hospital patients. Based on this 
information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we 
decided that the Plan does not have to pay for the lab testing services provided on December 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the PureWick Urine collection system and 
external catheter wicks provided from October 28, 2021, to December 20, 2021. 
 
You asked the Plan to waive the coinsurance for the PureWick Urine collection system and external catheter 
wicks. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your 
request. The Plan says they have partially overturned their denial and are reprocessing the claim for 
payment/reimbursement minus the enrollee's coinsurance per the enrollee's contract with the Plan. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a 20% coinsurance for Durable Medical Equipment.   
The enrollee has been asked to pay a 20% coinsurance for the PureWick Urine collection system and external 
catheter wicks. The PureWick Urine collection system and external catheter wicks fall within the Durable 
Medical Equipment benefit category. This means that the enrollee has been asked to pay the correct amount 
based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay 
upon enrolling in the Plan. Once the Plan has reprocessed the claim for payment, the enrollee will only be 
responsible for the coinsurance amount for these items. Therefore, we decided that the Plan does not have to 
waive the coinsurance for the PureWick Urine collection system and external catheter wicks provided from 
October 28, 2021, to December 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lung cancer panel provided on December 20, 2021. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says one code must 
be submitted for the panel. 
 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 gene panel was billed with multiple codes. If a single procedure is performed, only one code 
with one unit of service may be reported for the procedure. 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 lung cancer panel provided on December 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on November 4, 2021. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the testing is 
not a Medicare benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
 We looked at the file and the rules. In this case, there are insufficient records from the enrollees treating 
physician to show that the testing will impact clinical management of the enrollees medical condition. Based 
on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that 
the Plan does not have to pay for the gene panel testing provided on November 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for the out-of-network surgery services 
provided on January 4, 2022. 
 
You asked the Plan to reduce the cost share for the services provided. You say that you were not told the 
service would be considered out-of-network. The Plan denied your request. The Plan says the claim processed 
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 45% 
coinsurance for out-of-network outpatient surgery.  
 
You have been asked to pay a 45% coinsurance for the services provided. The services fall within the 
outpatient surgery 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 cost share for the out-of-network 
surgery services provided on January 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on March 9, 2021. 
 
You asked the Plan to pay for the testing services. You say that the diagnosis enabled the physician to 
determine optimal treatment. The Plan denied your request. The Plan says the testing should be reported with 
CPT 81479. 
 
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 looked at the file and the rules. The coding guidelines require the testing be billed with code 81479. The 
claim information shows that the testing was billed with multiple codes. Based on this information, we decided 
that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan 
does not have to pay for the Guardant360 testing provided on March 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 PWC with a single power option (K0856) 
and attachments. 
 
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 the member does not have medical need for single power option 
included with K0856 group 3 power wheelchair. 
 
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 member has a 
neurologic disorder with functional deficits. The documentation does not indicate that the member has any 
pressure injuries or requires intermittent catheterization of the bladder that would necessitate power tilt or 
recline. The requested electrical accessories are not medically necessary as the member does have use of the 
upper extremity and can operate and control the power options using the switches that are included in the basic 
wheelchair. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for 
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 a Group 3 PWC with a single power option (K0856) and attachments.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on January 12, 2022, by an out-of-
network provider. 
 
You asked the Plan to pay for the office visit. You say that the doctor should not be penalized for the hospital 
staff's failure in taking the proper steps to obtain authorization for the services. The Plan denied your request. 
The Plan says the provider is not a network provider and services are not urgent or emergent, nor were they 
approved in advance. 
 
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 office visit provided on January 12, 2022, by 
an out-of-network provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an out of network mental health visit 
provided on December 15, 2021. 
 
You asked the Plan to waive the copayment for a mental health visit. You say that you were never told the 
provider was out of network. 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 $55 
copayment for each Medicare covered individual or group therapy visit with an out of network psychiatrist.  
 
You have been asked to pay $55 copayment for out of network mental health visit. Mental health visits fall 
within the Outpatient Mental Health 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 an out of network mental health visit provided on December 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the services the enrollee needs could be provided in another 
setting, such as an acute rehabilitation facility, skilled nursing facility, nursing facility, outpatient setting or 
home care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee 
does not require services at the LTACH that are not available at the acute care hospital where he is currently 
receiving care. All medically necessary care is being provided in the current acute care setting. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to waive the cost for the rabies treatments during the ER visit provided on 
September 4, 2021. We decided that the Plan does not have to waive the cost for the additional rabies 
treatments and office visit.  
 
You asked the Plan to waive the cost for the ER visit, rabies treatments and office visit. You say that its not 
fair you are being punished more by having to pay for being attacked by a dog. The Plan denied your request. 
The Plan says that the claims processed correctly. 
 
We decided that the Plan has to reduce the cost for the rabies treatments during the ER visit.  
 
The Plan says you must pay 20% coinsurance for the rabies treatments during the ER visit provided on 
September 4, 2021. Your contract with the Plan clearly says you only pay a $90 copayment for Medicare-
covered emergency room visits. Therefore, we decided that the Plan has to reduce the cost for the rabies 
treatments during the ER visit from $482.24 to $90.  
 
We also decided that the Plan does not have to waive the cost for the additional rabies treatments and 
office visit. 
 
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% for 
Medicare Part B covered drugs and a $40 copayment for each specialist visit. Therefore, we decided that the 
Plan does not have to waive the cost for the additional rabies treatments and office visit for the remaining dates 
of service. 
 
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.