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

 
We decided that the Plan does not have to pay for the genetic testing provided on August 19, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis CPT code.  
 
We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple 
codes. Per Medicare rules, the testing should be reported with one unit of one CPT code. 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 genetic testing provided on August 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visits provided on February 18, 2022 
and March 11, 2022. 
 
You asked the Plan to waive the copayment for office visits. You say that this was a pre and post operative 
appointment and you should be covered in full.  The Plan denied your request. The Plan says you have been 
charged the correct copayment 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 $45 
copayment per visit for an in-network specialist.  
 
You have been asked to pay a total of $90 ($45 x 2 visits = $90). The 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 visits provided on February 18, 2022 and March 11, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of the pelvis. 
 
You asked the Plan to pre-approve an MRI of the pelvis. You say that an MRI is medically necessary. The Plan 
denied your request. The Plan says an MRI is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
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 an MRI of the pelvis. Our reviewer says 
that an MRI of the pelvis is not medically necessary. Our physician reviewer found that the medical records 
show a negative digital rectal exam. The prostate-specific antigen (PSA) is mildly elevated but stable. Despite 
prior negative transrectal ultrasound (TRUS) biopsy, which was negative there still is a concern for prostate 
cancer. While an MRI may be useful, the exam without fused ultrasound makes no sense. In fused scans a focal 
area of suspected malignancy could be detected but the fused ultrasound is necessary in order to a targeted 
biopsy, which is particularly important in a patient with prior negative random TRUS guided biopsy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the pelvis have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an MRI of the pelvis.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
August 14, 2021, to September 11, 2021. 
 
You asked the Plan to pay for the service provided. You say that a plan of care was signed by the physician. 
The Plan denied your request. The Plan says a corrected claim is needed. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on the information provided, we 
decided that Medicare rules for completing the claim have not been met. Therefore, we decided that the Plan 
does not have to pay for the home health services provided to the enrollee from August 14, 2021, to September 
11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing provided on April 7, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the lab results 
do not support the coding 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, the CPT Code Manual definition of code G0483 is definitive drug testing for 22 or more drug 
classes. We find that CPT code G0483 is not supported in the medical record. The records provided do not 
show that 22 or more drug classes were tested.  
 Based on this information, we decided that Medicare rules for coverage of the services provided have not been 
met. Therefore, we decided that the Plan does not have to pay for the definitive drug testing provided on April 
7, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transport (A0428) and ground 
mileage (A0425) provided on January 6, 2022, from the doctor's office to the nursing home. 
 
You asked the Plan to pay for the ambulance services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the ambulance services were not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance services. Our reviewer says 
that the ambulance services were not medically necessary. Our physician reviewer found the provided 
documentation does not indicate that the enrollee required the expertise of trained personnel or the equipment 
available only on an ambulance in order to effectuate a safe transport.  The reviewer found that transportation 
could have been provided by other means (stretcher van, wheelchair van) without endangering the enrollees 
condition. Therefore, the reviewer found that the ambulance services were not medically reasonable or 
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 ambulance services have not been met. Therefore, we decided that the Plan 
does not have to pay for the non-emergency ambulance transport (A0428) and ground mileage (A0425) 
provided on January 6, 2022, from the doctor's office to the nursing home.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stance flexion feature (L5845) for an OttoBock knee 
unit (3R60). 
 
You asked the Plan to pre-approve the feature. You say that this code is a vital part of the knee unit. The Plan 
denied your request. The Plan says the vendor and manufacturer do not have the ability to assign codes. 
 
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 L5845 is "Addition, endoskeletal, knee-shin system, 
stance flexion feature, adjustable." 
 
 We find that HCPCS code L5845 is not supported in the medical record. Specifically, L5845 is not considered 
an approved code for the base knee unit that was approved in this case. Based on this information, we decided 
that Medicare rules for coverage of the feature have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a stance flexion feature (L5845) for an OttoBock knee unit (3R60).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on November 10, 2021 by a non-
contracted ophthalmologist. 
 
You asked the Plan to pay for the office visit. You say that you went to a non-contracted ophthalmologist 
because you had a severe eye infection. The Plan denied your request. The Plan says you self-referred to a non-
plan ophthalmologist. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when you are seen by a contracted vision provider. 
 
We looked at the file and the Plan's rules. The record shows that you went to a non-contracted ophthalmologist. 
Your plan only covers vision services when they are rendered by a contracted provider. Based on this 
information, we decided that the Plan's rules for coverage of the office visit have not been met. Therefore, we 
decided that the Plan does not have to pay for the office visit provided on November 10, 2021 by a non-
contracted ophthalmologist.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography coded 70450 provided on 
December 15, 2021. 
 You asked the Plan to pay for the computed tomography. 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 separately payable. 
 
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 the computed tomography coded 70450 provided on December 
15, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic imaging services provided on December 1, 
2021. 
 
You asked the Plan to pay for the services provided. You say that you would like the bills to be paid. The Plan 
denied your request. The Plan says an explanation of benefits is needed before the claim can be considered. 
 
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. We looked at the file and the rules. The Plan has met its obligation with regards to coordination of benefits. 
Specifically, the Plan has directed the provider to send the bill to the primary insurer. As the secondary insurer, 
the Plan cannot be held responsible for the services until the primary insurer has denied the claim for these 
services. Therefore, we decided that the Plan does not have to pay for the diagnostic imaging services provided 
on December 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special anesthesia service (99100) provided on January 
10, 2022.  You asked the Plan to pay for the special anesthesia service (99100). The Plan denied your request. The Plan 
says procedure code 01402 is being handled as first-level claim review and procedure code 99100 remains 
denied as bundled services are not eligible for separate reimbursement. 
 
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 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the special anesthesia service (99100) have not been met. Therefore, we decided that the Plan does not have 
to pay for the special anesthesia service (99100) provided on January 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a continuous glucose monitor (K0553) 
provided on November 23, 2021. 
 
You asked the Plan to waive the coinsurance for the continuous glucose monitor. You say that the services 
should be covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-
sharing applied correctly based on the services provided. 
 
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) and related supplies.  
 
 
  You have been asked to pay a 20% coinsurance for a continuous glucose monitor (allowed is $1,250 x 20% = 
$250). Continuous glucose monitors fall 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 a continuous glucose monitor 
(K0553) provided on November 23, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Emergency Room Services provided on 
December 30, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to waive the copayment for Emergency Room Services. You say that this should have been 
my urgent care copayment. 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 $65 
copayment for Emergency Room Services.  
 
You have been asked to pay a $65 copayment for Emergency Room Services. Emergency Room Services 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 copayment for Emergency 
Room Services provided on December 30, 2021 by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit (99283) provided 
on January 30, 2022. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 per emergency department visit.  
 
You have been asked to pay a $90 copayment for the emergency department visit provided. 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 emergency room visit (99283) provided on 
January 30, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on January 10, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the services should be covered. The Plan 
denied your request. The Plan says that the claim was processed per multiple pages in the Evidence of 
Coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The plan has given no information as to why this case was denied. The Plan said 
the claim was processed per multiple pages in the Evidence of Coverage without any specifics, and it is not 
clear from the limited case if the amount owed is for cost-sharing, or if the amount owed is due to services 
being denied. Therefore, we decided that the Plan has to pay for the laboratory services provided on January 
10, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PGx pharmacogenetics panel (CPT code(s): 81283-90, 
81241-90, 81240-90, 81238-90, 81231-90, 81230-90, 81232-90, 81227-90, 81355-90, 81328-90, and 81291-
90) provided on November 4, 2021. 
 You asked the Plan to pay for the laboratory services. You say that these are payable by Medicare and were 
denied as experimental in error. The Plan denied your request. The Plan says the Medicare rules have not been 
met. 
 
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 laboratory services. Our physician 
reviewer found the clinical notes did not clearly show that there were plans or clinical support for using 
multiple drug classes for various conditions. The notes suggest testing for pain medications with potential gene 
interactions would be reasonable but no other classes. Therefore, this request for 61 genes is excessive and not 
supported in the documentation and will be considered not 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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the PGx pharmacogenetics panel (CPT code(s): 81283-90, 81241-90, 81240-90, 
81238-90, 81231-90, 81230-90, 81232-90, 81227-90, 81355-90, 81328-90, and 81291-90) provided on 
November 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services provided to the enrollee from December 
1, 2020, to December 31, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider did not bill as required by Medicare coding regulations. 
 
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 90960 is not supported in the medical record. Specifically, this code has a status 
indicator of "M" which means it is not billable to the Medicare Administrative Contractor (MAC). As this main 
code is not billable to this plan, the rest of the codes also cannot be billed. 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 outpatient services provided to the enrollee from 
December 1, 2020, to December 31, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99309) 
rendered by the out-of-network (OON) provider on November 24, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the subsequent nursing facility care, per day (99309) rendered by the out-of-network 
(OON) provider on November 24, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit provided from 
September 30, 2021, to October 2, 2021. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 
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 $120 
copayment for Emergency care.  
 
 
  You have been asked to pay a $120 copayment for an emergency room visit. 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 emergency room visit provided from September 30, 2021, to October 2, 2021.