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

 
We decided that the Plan does not have to pay for gene panel testing provided to the enrollee on July 6, 2021. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says there are genes tested that are not medically necessary for the enrollee's cancer diagnosis. 
 
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 testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found a request for broad molecular gene testing was made. However, it was not clearly described how the 
patient's treatment plan would be significantly changed based on the results of this genetic panel as this was for 
a broad panel and not a focused panel which would have been more appropriate considering this clinical 
scenario. There is insufficient support made that some of the tests in the broad panel (BCR/ABL1, KRAS for example) would lead to a clinically significant improvement in overall outcome compared to focused gene 
testing or even standard testing methods. Therefore, the criteria for the Tempus Gene Panel testing was not 
met. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for gene panel testing provided to the enrollee on July 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ophthalmic biometry (eye exam) 
provided on January 25, 2022. 
 
You asked the Plan to waive the copayment for the eye exam. You say that this was only a pre-op visit and 
should not have a copayment. 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 exam to diagnose and treat diseases and conditions of the eye.  
 
You have been asked to pay a $35 copayment for the eye exam. The eye exam falls within the Vision Services 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 ophthalmic biometry (eye 
exam) provided on January 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraspinal chiropractic manipulative treatment (code 
98943) and the electrical stimulation (code G0283) provided by a chiropractor on December 6, 2021. 
 
You asked the Plan to pay for the chiropractic services.. You say that these services were medically necessary. 
The Plan denied your request. The Plan says these are not Medicare-covered chiropractic services.  While the 
member does have a supplemental chiropractic benefit for non-Medicare covered chiropractic services, the 
member has exhausted that benefit for 2021. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. The Plan does have a 
supplemental chiropractic benefit that will cover chiropractic services beyond manual manipulation of the spine.  This benefit is limited to 30 visits each calendar year.  Records show that the member exhausted this 30-
visit maximum on December 3, 2021, so no additional non-Medicare covered chiropractic services are eligible 
for coverage after that date. Therefore, we decided that the Plan does not have to pay for the extraspinal 
chiropractic manipulative treatment (code 98943) and the electrical stimulation (code G0283) provided by a 
chiropractor on December 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic counseling provided on October 21, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the genetic counseling. You say that the claim was denied as a non-covered 
service. You say you would like the claim reprocessed. The Plan denied your request. The Plan says no prior 
authorization was obtained. 
 
 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 did not pre-approve the 
genetic counseling. We found no exception that would require the Plan to pay for the genetic counseling. The 
records provided for review do not show that the genetic counseling was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for genetic counseling provided on October 21, 2021, by an out-of-
network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT scan and low osmolar contrast 
material (74177, Q9967) provided on November 29, 2021. 
 
You asked the Plan to waive the copayment for the CT scan and low osmolar contrast material. 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 $175 
copayment and a 20% coinsurance for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
 You have been asked to pay a $175 copayment for a CT scan and a 20% coinsurance for low osmolar contrast 
material (allowed is $12.12 x 20% = $2.42). CT scans and low osmolar contrast materials 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 copayment for a CT scan and low osmolar contrast material (74177, Q9967) provided on 
November 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for oxygen equipment (E0601, A7038) 
provided on January 15, 2022 
 
You asked the Plan to waive the coinsurance for the oxygen equipment. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the coinsurance 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 oxygen equipment. 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 oxygen equipment (E0601, A7038) provided on January 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 83850, 86880, 86900, 86901, and 86902 billed for date 
of service November 14, 2021. 
 
You asked the Plan to pay for codes 83850, 86880, 86900, 86901, and 86902. You say that this claim was 
underpaid. The Plan denied your request. The Plan says no separate payment is made for these 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. 
 We find that CPT codes 83850, 86880, 86900, 86901, and 86902 have a status indicator of N. This means that 
CPT codes 83850, 86880, 86900, 86901, and 86902 are not separately payable. Based on this information, we 
decided that Medicare rules for coverage of codes 83850, 86880, 86900, 86901, and 86902 have not been met. 
Therefore, we decided that the Plan does not have to pay for codes 83850, 86880, 86900, 86901, and 86902 
billed for date of service November 14, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services provided on 
January 4, 2022. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you tried to contact the 
Plan unsuccessfully and feel you should not be charged. The Plan denied your request. The Plan says the 
copayment amount 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 you must pay a $100 
copayment for each Medicare-covered emergency room visit.  
 
You have been asked to pay a $100 copayment for emergency room services. Emergency room services fall 
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 January 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided the Plan does not have to pay for genetic testing provided to the enrollee on September 30, 2021. 
 
You asked the Plan to pay for this testing. You say that this testing should be covered by the Plan. The Plan 
denied your request. The Plan says Medicare coverage criteria were not met. 
 
The Plan must follow Medicare rules. Medicare has specific coverage criteria for this testing. 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 this testing. Our physician reviewer found the patient is an 
80-year-old female with breast cancer who underwent Genomic testing (Oncotype DX Breast Recurrence Score 
test). She underwent biopsy for a suspicious mass in the right breast revealing grade 3 invasive ductal 
carcinoma, 12 mm, with focal suspicious DCIS but negative lymphovascular invasion, ER 100%, PR 85%, 
HER-2 equivocal, KI-87 20+%. No lymph node was provided in the surgical sample which suggests and 
unknown lymph node status and unconfirmed HER 2 statuses. However, this testing is not validated for use in 
neoadjuvant therapy without this information. Therefore, the criteria for this testing were not met.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this testing have not been met. Therefore, we decided that the Plan does not 
have to pay for genetic testing provided to the enrollee on September 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a targeted genomic sequence analysis panel provided to the 
enrollee on August 3, 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 this testing is unlikely to impact therapeutic decision-making in the clinical management of the 
patient. 
 
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 the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found with malignant neoplasm of connective and soft tissue, unspecified, liposarcoma with imaging 
suggestive of metastatic disease in the setting of breast cancer history. A targeted genomic sequence analysis panel (51+ genes) was performed and requested. However, the clinical records did not support this testing. 
There was insufficient support made suggesting this testing would lead to a significant change in the treatment 
plan for this patient or lead to a clinically significant improvement in overall outcome. Therefore, the enrollee 
does not meet criteria for this testing.  
 
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 a targeted genomic sequence analysis panel provided to the enrollee on August 3, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy (45378) provided on 
December 22, 2021. 
 
You asked the Plan to waive the copayment for the colonoscopy. 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 $325 
copayment for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
 
  You have been asked to pay a $325 copayment for the colonoscopy. Colonoscopies fall within the Outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for a colonoscopy (45378) provided on December 
22, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an MRI provided on May 26, 2021. 
 
You asked the Plan to waive the copayment for an MRI. You say that you believe you should only be charged 
one copayment since both tests were performed on the same day. The Plan denied your request. The Plan says 
the copayment 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 $150 
copayment for all other diagnostic and nuclear medicine radiological services performed in a contracted 
facility. Your contract with the Plan also clearly says that if multiple test types (such as CT and PET) are 
performed in the same day, multiple copayments will apply. You have been asked to pay a $150 copayment for an MRI. An MRI 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 waive the copayment for 
an MRI provided on May 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraspinal chiropractic manipulative treatment (code 
98943) and the electrical stimulation (code G0283) provided by a chiropractor on December 20, 2021. 
 
You asked the Plan to pay for the chiropractic services.. You say that these services were medically necessary. 
The Plan denied your request. The Plan says these are not Medicare-covered chiropractic services.  While the 
member does have a supplemental chiropractic benefit for non-Medicare covered chiropractic services, the 
member has exhausted that benefit for 2021. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 The records show that the services at issue are not manual manipulation of the spine. The Plan does have a 
supplemental chiropractic benefit that will cover chiropractic services beyond manual manipulation of the 
spine.  This benefit is limited to 30 visits each calendar year.  Records show that the member exhausted this 30-
visit maximum on December 3, 2021, so no additional non-Medicare covered chiropractic services are eligible 
for coverage after that date. Therefore, we decided that the Plan does not have to pay for the extraspinal 
chiropractic manipulative treatment (code 98943) and the electrical stimulation (code G0283) provided by a 
chiropractor on December 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an ECG provided on January 20, 2022. 
 
You asked the Plan to waive the deductible for the ECG. 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. Your 
contract with the Plan says that there is a $300 deductible which applies to Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies.  
 
 
  The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $300 deductible which applies to Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies. This cost sharing is a contractual obligation that had not been met at the 
time the ECG was received on January 20, 2022. Therefore, we decided that the Plan does not have to waive 
the deductible for an ECG provided on January 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services rendered on August 19, 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 procedure code 99152 is 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 99152 is moderate sedation services by other qualified 
health care professional requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status, patient 5 years of age or older, first 15 minutes. 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, there is no documentation of 
the first 15 minutes of an independent trained observer to assist in monitoring the patient's level of 
consciousness and physiological status. 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 moderate 
sedation services rendered on August 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the biopsy provided by a network facility 
on January 6, 2022. 
 
You asked the Plan to reduce the copayment for the biopsy. You say that you were told you would only have a 
$40 copayment for the surgery. You say you would not have had the procedure done if you knew the 
copayment was $325. The Plan denied your request. The Plan says you have been asked to pay 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 $325 
copayment per date of service at an outpatient hospital facility.  
 
 You have been asked to pay a $325 copayment for the biopsy. The biopsy falls within the Outpatient surgery, 
including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. 
The record shows you were billed by the outpatient hospital facility. 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 the biopsy provided by a network facility on January 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiovascular genetic testing provided to the enrollee on 
October 11, 2021. 
 
You asked the Plan to pay for to pay for. You say that this should be paid for. The Plan denied your request. 
The Plan says Medicare Part B covers cardiovascular disease screening tests when ordered by the physician 
who is treating the beneficiary for the purpose of early detection of cardiovascular disease in individuals 
without apparent signs or symptoms of cardiovascular disease. 
 
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 to pay for. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found cardiovascular gene panel testing was requested. Vitals were normal. The patient reported mild shortness of breath. Other testing was also performed for screening purposes (lipid panel). However, the provided 
documentation did not describe how the gene testing would lead to a significant change in treatment or overall 
outcome for this patient to support this request. Therefore, this request for cardiovascular gene panel testing 
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 to pay for have not been met. Therefore, we decided that the Plan does not have 
to pay for cardiovascular genetic testing provided to the enrollee on October 11, 2021.