Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an acute inpatient stay provided on August 
06, 2023, to August 08, 2023. 
 
You asked the Plan to waive the copayment for an acute inpatient stay. You say that this was enough of an 
emergency that you were hospitalized. The Plan denied your request. The Plan says this cost sharing was 
charged 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 $300 
copayment for inpatient hospital care. 
 
You have been asked to pay a $300 copayment for an acute inpatient stay. This item/service falls 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. You have been asked to pay a $300 copayment for the inpatient hospital stay. Therefore, 
we decided that the Plan does not have to waive the copayment for an acute inpatient stay provided on August 
06, 2023, to August 08, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for pathology services provided on June 14, 
2023. 
 
You asked the Plan to waive the coinsurance for pathology services. You say that this was at an in-network 
facility, and no one told you that you would have a coinsurance bill for this service. The Plan denied your 
request. The Plan says this cost sharing was charged 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 40% 
coinsurance for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay 40% coinsurance for pathology services. This item/service 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. The total you owe is $59.30 ($148.24 x 40% = 
$59.30) for an out-of-network pathology service. Therefore, we decided that the Plan does not have to waive 
the coinsurance for pathology services provided on June 14, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three skilled nursing and four PT visits. 
 You asked the Plan to pre-approve the three skilled nursing and four PT visits. You say that the services are 
medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 three skilled nursing and the four 
PT visits. Our reviewer says that the services are not medically reasonable and necessary. Our physician 
reviewer found the documentation doesnt support that the enrollee requires additional skilled nursing services 
or skilled rehab services to provide treatment that is medically necessary. The enrollee does not require 
additional skilled nursing or rehab services to effectively provide treatment, care, or services in order to 
improve the enrollees condition. The enrollee has been medically stable without any recent exacerbations of 
chronic medical problems or hospitalizations. The requested home health services are 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 three skilled nursing and the four PT visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve three skilled nursing and four PT visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 CDx testing (81479) provided on May 17, 
2023. 
 
You asked the Plan to pay for the Guardant360 CDx testing (81479). You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the claim for this molecular 
pathology testing did not include the required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that a valid unique identifier was 
reported. The unique identifier, Z031D, is not a valid code for the provided Guardant360 CDx testing. Based 
on this information, we decided that Medicare rules for coverage of the Guardant360 CDx testing (81479) have 
not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 CDx testing 
(81479) provided on May 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
August 16, 2023, and billed with codes 87500, 87641, 87798, G0452, 87491, 87496, 87529, 87532, 87563, 
87591, 87481, 87651, and 87653. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says per Local Coverage Article (LCA) A58726, this type of testing must be 
billed as a single unit of service with a single code. 
 The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on August 16, 2023, 
and billed with codes 87500, 87641, 87798, G0452, 87491, 87496, 87529, 87532, 87563, 87591, 87481, 87651, 
and 87653.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Avertix Guardian System (0525T, C1833). 
 
You asked the Plan to pre-approve the Avertix Guardian System. You say that this is medically necessary for 
the enrollee. The Plan denied your request. The Plan says this is experimental and therefore is not covered. 
 
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 the Avertix Guardian System. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found an exhaustive review of the current medical literature pertaining to the 
Avertix Guardian system confirms several observational studies suggesting clinical benefit. While the clinical 
studies led to Food and Drug Administration (FDA) approval, the Avertix Guardian system remains the subject 
of studies assessing long-term efficacy, as well as randomized, controlled, blinded trials to quantify clinical 
efficacy. Until such statistically rigorous studies are completed, it is premature to presume clinical outcomes 
and benefit. At the current time, the Avertix Guardian system is not medically necessary for this enrollee. 
 
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 Avertix Guardian System have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Avertix Guardian System (0525T, C1833).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0452 billed for date of service July 31, 
2023. 
 You asked the Plan to pay for procedure code G0452. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code G0452 is bundled into payment for code 81206. 
 
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 G0452 
is a column II code to column I code 81206. 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 procedure code G0452 billed for date of service July 31, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested device is medically necessary. 
You also say that the provider believes this will decrease the enrollee's hospital readmissions. The Plan denied 
your request. The Plan says noninvasive ventilators used solely as a respiratory assistive device (RAD) are 
considered not reasonable and necessary per Medicare Guidelines. The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee does not have substantial 
evidence to recommend home ventilator per documentation provided. The enrollee does have COPD with 
chronic respiratory failure but no indication that has failed BIPAP trial or progression of failure on BIPAP 
therapy. Hence, the home ventilator does not meet criteria for approval. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on January 16, 2023. 
 
You asked the Plan to pay for laboratory services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory services 
provided on January 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the injection services provided on July 07, 
2023. 
 
You asked the Plan to waive the copayment for the injection services. You say that you were not told that you 
would be charged for surgery. The Plan denied your request. The Plan says this cost sharing was charged 
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 $325 
copayment for outpatient hospital services. 
 
You have been asked to pay a $325 copayment for the injection services. This item/service falls within the 
outpatient hospital 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 the injection 
services provided on July 07, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on April 14, 2023, to June 30, 2023. 
 
You asked the Plan to pay for psychotherapy. You say that the services should be covered. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for psychotherapy provided 
on April 14, 2023, to June 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and related services provided on April 07, 
2023. 
 
You asked the Plan to pay for an office visit and related services. You say that this service is supported in the 
records. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit and 
related services provided on April 07, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on 
September 01, 2023. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged 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 $100 
copayment for outpatient surgery/Medicare-coveredsurgery at an outpatient hospital. 
 
You have been asked to pay a $100 copayment for an outpatient surgery. This item/service falls within the 
outpatient surgery/Medicare-coveredsurgery at an outpatient hospital 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 outpatient surgery provided on September 01, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95822 and 95999 billed for date of service 
May 2, 2023. 
 
You asked the Plan to pay for the billed services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the billed codes are 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 95822 is electroencephalogram (EEG); recording in coma 
or sleep only. We find that CPT code 95822 is not supported in the medical record. The records do not show 
that this diagnostic testing was performed during a coma or sleep. We find that code 95999 was billed for train 
of four testing. Train of four testing is integral to the primary procedure and not separately payable. Based on 
this information, we decided that Medicare rules for coverage of the billed services have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 95822 and 95999 billed for date 
of service May 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), a panoramic x-ray 
(D0330) and an adult prophylaxis (D1110) provided on November 17, 2022. 
 
  You asked the Plan to pay for a periodic oral evaluation (D0120), a panoramic x-ray (D0330) and an adult 
prophylaxis (D1110). You say that payment was issued to the provider and the check was cashed on January 
17, 2023. You also say that payment was then issued to the enrollee for the same services on January 26, 2023, 
and the check was cashed on May 31, 2023. The Plan denied your request. The Plan says the member's medical 
Plan has an allowance for certain dental services. 
 
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 Plan covers a periodic 
oral evaluation (D0120), a panoramic x-ray (D0330) and an adult prophylaxis (D1110) when the services are 
medically necessary and reasonable.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a periodic oral evaluation (D0120), a panoramic x-ray (D0330) and an adult prophylaxis (D1110) 
have not been met. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation 
(D0120), a panoramic x-ray (D0330) and an adult prophylaxis (D1110) provided on November 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic comprehensive preventive examination provided 
on December 21, 2022. 
 
You asked the Plan to pay for a periodic comprehensive preventive examination. You say that the services 
were medically necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care 
is not covered. 
 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a periodic 
comprehensive preventive examination provided on December 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient surgery provided on August 
03, 2023. 
 
You asked the Plan to waive the copayment for the outpatient surgery. You say that the cost share is wrong. 
The Plan denied your request. The Plan says this cost sharing was charged 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 $275 
copayment for outpatient surgery. 
 
You have been asked to pay a $275 copayment for the outpatient surgery. This item/service falls 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 waive the copayment for the outpatient 
surgery provided on August 03, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the eye exam (92002), cataract surgery 
(66821), and post-op follow up visit (99024), provided on October 19, 2022, through November 7, 2022. 
 
You asked the Plan to waive the coinsurance for the vision services. You say that the services should be 
covered. The Plan denied your request. The Plan says this cost sharing was charged 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 20% 
coinsurance for vision services.  
 
You have been asked to pay a 20% coinsurance for the vision services. This item/service 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. A post-operative visit following a major surgery (66821), is not paid separately from the surgery itself. 
Therefore, we decided that the Plan does not have to waive the coinsurance for the eye exam (92002), cataract 
surgery (66821), and post-op follow up visit (99024), provided on October 19, 2022, through November 7, 
2022.