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

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
November 8, 2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you went to the ER due to 
dehydration and high potassium levels but blood tests determined that levels were normal. 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 $90 
copayment for each emergency care visit.  
 
The records show that you were evaluated and stabilized in the ER. Therefore, you have been asked to pay a 
$90 copayment for the ER visit. The ER 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 copayment for an emergency room (ER) visit provided on November 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be rendered by the out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says there are in-network providers available to render the 
requested service. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the service at issue in this appeal. We found no exception that would require the 
Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve an office 
visit to be rendered by the out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on June 30, 2021. 
 
You asked the Plan to pay for the Guardant360 testing. You say that POS code 81 is appropriate for these 
services. The Plan denied your request. The Plan says the POS reported does not reflect where this sample was 
taken. 
 
The Plan must follow Medicare rules. Medicare rules say that the Place of Service (POS) code is generally used 
to reflect the actual setting where the beneficiary receives the face to-face service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Guardant360 testing have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the member's face-to-face service was rendered in a laboratory 
setting. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on June 
30, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on October 15, 
2021. 
 
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. 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 imaging services provided to the enrollee on October 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on June 15, 2021. 
 
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 denied code was inclusive to another billed code. 
 
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 63012 
is a column II code to column I code 22633. 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 surgical services provided to the enrollee on June 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a shingles vaccine provided on November 10, 2021. 
 
You asked the Plan to pay for the shingles vaccine under Medicare Part B. You say that the shingles vaccine 
was recommended by your doctor. The Plan denied your request. The Plan says payment for the shingles 
vaccine must be submitted to your Medicare Part D insurance. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine 
under Medicare Part B. The Plan follows the same rules. The shingles vaccine is preventative and is not 
covered under Medicare Part B. Therefore, we decided that the Plan does not have to pay for a shingles vaccine 
provided on November 10, 2021. Benefits for the shingles vaccine may be available under Medicare Part D. 
Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal 
rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee 
from May 15, 2021, to May 20, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for these services. The enrollee also had 
exhausted the point of service out of network benefit. 
 
 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 contract also says the point of service out of network benefit 
requires prior authorization and has a benefit limit.  
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve these services. We 
found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan 
does not have to pay for out of network physician services provided to the enrollee from May 15, 2021, to May 
20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transesophageal echocardiography probe placement 
provided by the treating anesthesiologist on March 12, 2021, billed with code 93313-59. 
 
You asked the Plan to pay for the transesophageal echocardiography probe placement. You say that this is 
separately payable and cannot be included in the anesthesia code payment. The use of modifier -59 allows 
separately payment. The Plan denied your request. The Plan says the use of modifier -59 is not supported in 
this case. 
 
The Plan must follow Medicare rules. Medicare rules say that anesthesia payment is made via the Anesthesia 
Fee Schedule. The five-digit code is payment for all anesthesia related services. 
 
 There is no evidence that this probe placement was done for any other reason but to monitor during the 
anesthesia time. This was not a separate and distinct diagnostic service. Therefore, we decided that the Plan 
does not have to pay for the transesophageal echocardiography probe placement provided by the treating 
anesthesiologist on March 12, 2021, billed with code 93313-59.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital services provided from February 12, 2020, to 
February 15, 2020. 
 You asked the Plan to pay for the hospital services. You say that you believe the medical records support 
payment of this claim. The Plan denied your request. The Plan says it does not believe that metabolic 
encephalopathy was a valid diagnosis for this claim. The Plan agrees that the member presented with an altered 
mental status; however, there was no other condition aside from seizure activity and Dilantin toxicity that 
caused the alteration in mentation. The member's mental status did not improve and was documented as 
oriented x1 throughout the hospital stay. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code G93.41 (metabolic encephalopathy). 
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 hospital services. Our reviewer says that 
a diagnosis of G93.41 (metabolic encephalopathy) is not sufficiently supported by the medical records. Our 
physician reviewer found There was no metabolic cause of her symptoms such as infection or other 
abnormality which caused the enrollee's symptoms.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for hospital services provided from February 12, 2020, to February 15, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Avastin, Carboplatin, and Gemcitabine and supporting 
therapy for the enrollee. 
 
You asked the Plan to pre-approve the drugs. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested drug combination is not medically reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 drugs. Our reviewer says that the 
requested drug combination is not medically reasonable or necessary. Our physician reviewer found this 
regimen is not FDA approved for the enrollee's diagnosis. The use is not supported by any of the major 
compendia or by clinical research that appears in an approved medical journal. 
 
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 drugs have not been met. Therefore, we decided that the Plan does not have to pre-approve Avastin, Carboplatin, and Gemcitabine and 
supporting therapy for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an X-ray for swallowing function and oral 
function therapy services provided on November 17, 2021. 
 
You asked the Plan to waive the copayments for the X-ray and oral function therapy. You say that no therapy 
was performed, only the X-ray test. 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 $35 
copayment for each X-ray, diagnostic procedure, and test. Your contract with the Plan also clearly says that you must pay a $20 copayment for each therapy visit. 
 
You have been asked to pay a $35 copayment for the X-ray. The X-ray falls within the Outpatient Diagnostic 
Tests and Therapeutic Services and Supplies benefit category. You have also been asked to pay a $20 
copayment for the oral function therapy. The oral function therapy falls within the Outpatient Rehabilitation 
Services benefit category. The total for the visit is $55. 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 copayments for 
an X-ray for swallowing function and oral function therapy services provided on November 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a magnetic resonance imaging (MRI) of 
the neck and a nerve conduction study provided on September 24, 2021. 
 
You asked the Plan to waive the copayments for the MRI and nerve conduction study. You say that you are on 
a fixed income and cannot afford the bill. 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 $250 
copayment for diagnostic radiology services in an outpatient hospital facility. 
 
Your contract with the Plan also clearly says that you must pay a $175 copayment for each non-radiological 
diagnostic procedure or test at an outpatient hospital facility.  
You have been asked to pay $209.10 for the MRI, which is less than the $250 copayment. You have also been 
asked to pay a $175 copayment for the nerve conduction study. The total for both tests is $384.10. The MRI 
and nerve conduction study fall 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 waive the copayments for a magnetic resonance imaging 
(MRI) of the neck and a nerve conduction study provided on September 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from 
August 27, 2021, to September 1, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you cannot afford 
to pay such a high copayment. You say that you would like the copayment reduced due to your COVID -19 
diagnosis. 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 $390 per 
day for days 1-5 and $0 per day after day 5 for each hospital admission.  
 
 
 The file shows that you were in the hospital from August 27, 2021, to September 1, 2021. The file also shows 
that the Plans COVID-19 cost share waivers were no longer in effect as of June 1, 2021. Therefore, you have 
been asked to pay $390 per day for the first 5 days of inpatient hospital services. The total for your stay is 
$1,950 ($390 copayment x 5 days = $1,950). The inpatient hospital services fall within the Inpatient Hospital 
Care benefit category. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital services 
provided from August 27, 2021, to September 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the suction-assisted truncal lipectomy provided on 
September 16, 2021. 
 
You asked the Plan to pay for the suction-assisted truncal lipectomy. You say that this type of service is legally 
required to be covered due to Federal law. The Plan denied your request. The Plan says this is a cosmetic 
procedure that is excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 suction-assisted truncal lipectomy. Our 
reviewer says that the services provided in this case are deemed cosmetic in nature and are not considered 
medically reasonable and necessary. Our reviewer found the enrollee underwent a reconstruction in 2019. The record does not include documentation that a subsequent cancer operation was performed. The record as 
provided indicates that the procedure was cosmetic in nature. The elements of the coverage criteria are not 
satisfied.  
 
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 suction-assisted truncal lipectomy have not been met. Therefore, we decided 
that the Plan does not have to pay for the suction-assisted truncal lipectomy provided on September 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing (81479) provided on September 5, 
2021. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says this claim was billed with the incorrect 
place of service code. 
 
The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare 
Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting 
where the beneficiary receives the face to-face service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Guardant360 testing have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the enrollee's face-to-face service was rendered in a laboratory 
setting. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing (81479) provided 
on September 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on October 29, 2021. 
 
You asked the Plan to pay for the Guardant360 testing. You say that the provided Guardant360 testing was 
medically necessary. The Plan denied your request. The Plan says the enrollee did not meet criteria for the 
provided Guardant360 testing. 
 
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 Guardant360 testing. Our reviewer says 
that the enrollee did not meet criteria for the provided Guardant360 testing. Our physician reviewer found per 
the National Comprehensive Cancer Network (NCCN) Guidelines liquid biopsy such as with Guardant360 
should be used only in specific clinical circumstances, most notably, if a patient is medically unfit for invasive 
tissue sampling. In the initial diagnostic setting, if following pathologic confirmation of a NSCLC diagnosis 
there is insufficient material for molecular analysis, cell-free/circulating tumor DNA should be used only if 
follow-up tissue-based analysis is planned for all patients in which an oncogenic driver is not identified. This 
criterion is not met for this enrollee as not stated that no tissue is available for testing. The service is not 
reasonable or 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 Guardant360 testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the Guardant360 testing provided on October 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 4, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that genetic testing procedures submitted under CPT code 
81455 are denied as not medically necessary. 
 
We looked at the file and Medicare rules. The services are billed under code 81455. 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 August 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BRCA genetic testing. 
 
You asked the Plan to pre-approve BRCA genetic testing. You say that the enrollee has a history of cancer 
within her family. The Plan denied your request. The Plan says the requested testing is not a covered benefit for 
the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that BRCA1/BRCA2 genetic testing is non-covered 
for individuals with no personal history of breast, ovarian, fallopian tube, primary peritoneal, pancreatic, or 
prostate cancer. 
 
We looked at the file and Medicare rules. The records provided do not show that the enrollee has a person 
history of breast, ovarian, fallopian tube, primary peritoneal, pancreatic, or prostate cancer. Based on this 
information, we decided that Medicare rules for coverage of BRCA genetic testing have not been met. 
Therefore, we decided that the Plan does not have to pre-approve BRCA genetic testing.