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

 
We decided that the Plan does not have to waive the copayment for an out-of-network ambulance ride provided 
on June 02, 2023. 
 
You asked the Plan to waive the copayment for an out-of-network ambulance ride. You say that you had to go 
to the emergency room, and were admitted. You should not have to pay another 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 $325 
copayment for ambulance services. 
 
You have been asked to pay a $325 copayment for an out-of-network ambulance ride. This item/service falls 
within the ambulance 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. However, since the allowed amount is less than the standard copayment, you only owe 
$212. Therefore, we decided that the Plan does not have to waive the copayment for an out-of-network 
ambulance ride provided on June 02, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ear, nose, and throat (ENT) visit 
provided on August 28, 2023. 
 
You asked the Plan to waive the copayment for an ear, nose, and throat (ENT) visit. You say that this was a 
follow up visit and should not have a copayment. You paid for the previous copayment already. 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 $40 
copayment for hearing services. 
 
You have been asked to pay a $40 copayment for an ear, nose, and throat (ENT) visit. This item/service falls 
within the hearing 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 ear, nose, 
and throat (ENT) visit provided on August 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a specialist visit, a primary care visit, and 
a laboratory visit provided from July 17, 2023, to August 18, 2023. 
 
You asked the Plan to waive the copayments for a specialist visit, a primary care visit, and labs. You say that 
you do not feel you should have to pay these copayments. 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 $5 
copayment, a $35 copayment, and a $40 copayment for physician/practitioner services, including doctors 
office visits, and outpatient diagnostic tests and therapeutic services and supplies.  You have been asked to pay an $80 total copayment for a specialist visit, a primary care visit, and labs ($40 
specialist + $35 primary care + $5 labs = $80). This item/service falls within the physician/practitioner 
services, including doctors office visits, and 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 specialist visit, a primary care 
visit, and a laboratory visit provided from July 17, 2023, to August 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on July 13, 2023. 
 
You asked the Plan to pay for the dental services. You say that you had a cleaning available for the year. The 
Plan denied your request. The Plan says your annual dental allowance amount has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your $2,000 annual dental allowance amount was exhausted on date of service January 11, 2023. 
Therefore, we decided that the Plan does not have to pay for dental services provided on July 13, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 95939-TC, 51785-TC, 95938-TC, 95911-
TC-59, 95886-TC, 95940-59, A4215, and A4556 billed for date of service December 5, 2022. 
 
You asked the Plan to pay for procedure code(s) 95939-TC, 51785-TC, 95938-TC, 95911-TC-59, 95886-TC, 
95940-59, A4215, and A4556. You say that the claim is billed correctly and should be paid. The Plan denied 
your request. The Plan says these codes are included in the facility payment and are not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 95939-TC, 51785-TC, 
95938-TC, 95911-TC-59, 95886-TC, 95940-59, A4215, and A4556. This means there is both a professional 
and technical component for the CPT code(s). In this case, an appropriate modifier to indicate the professional 
component has not been billed with CPT code(s) 95939-TC, 51785-TC, 95938-TC, 95911-TC-59, 95886-TC, 
95940-59, A4215, and A4556. Based on this information, we decided that Medicare rules for coverage of 
procedure codes 95939-TC, 51785-TC, 95938-TC, 95911-TC-59, 95886-TC, 95940-59, A4215, and A4556 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code(s) 95939-TC, 
51785-TC, 95938-TC, 95911-TC-59, 95886-TC, 95940-59, A4215, and A4556 billed for date of service 
December 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2331) for tooth #2 provided on 
September 1, 2023. 
 
You asked the Plan to pay for D2331. You say that these services should be considered preventive. The Plan 
denied your request. The Plan says the rendered dental service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a resin-
based composite (D2331) for tooth #2 provided on September 1, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services billed with code 43644 for May 17, 
2023. 
 
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 claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that primary diagnosis as E66.01 (morbid obesity) must be 
billed for bariatric surgery codes. 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with the required primary 
diagnosis code E66.01. 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 surgical services 
billed with code 43644 for May 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341 billed for date of service August 9, 
2023.  
 
You asked the Plan to pay for procedure code 88341. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88341 is 13. The MAI value for this code is 3. You billed 19 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 88341 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88341 billed for date of service August 9, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the PrismRA Molecular Signature test (81479) provided on April 17, 
2023. 
 
You asked the Plan to pay for the PrismRA Molecular Signature test. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says that this test is non-covered under MolDX. 
 
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. We find that the DEX diagnostics registry shows that the PrismRA test is 
covered under Medicare. Thus, the Plans denial rationale is not supported.  Therefore, we decided that the Plan 
has to pay for the PrismRA Molecular Signature test (81479) provided on April 17, 2023.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the breathing test and an office visit on 
September 12, 2023, to September 14, 2023.  
 
You asked the Plan to waive the coinsurance for the breathing test and an office visit. You say that you would 
like your in-network benefits applied to these claims. 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 x-rays, diagnostic procedures and tests, and diagnostic radiology services. You must pay a 20% 
coinsurance per specialist in-person or telehealth visit. 
 
You have been asked to pay a 20% coinsurance for the breathing test and an office visit. This item/service falls 
within the outpatient diagnostic tests and therapeutic services and supplies and physician/practitioner services, 
including doctors office visits benefit category. The total amount you owe is $62.52, which is 20% 
coinsurance of the allowed amount for each item. 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 
the breathing test and an office visit on September 12, 2023, to September 14, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 4, 2023, billed with 
codes 81225 x1, 81328 59 x1, 81335 x1, 81479 GY 59 x1, 81238 59 x1, 81226 x1, 81227 59 x1, 81231 59 x1, 
81232 59 x1, 81240 59 x1, 81241 59 x1, 81291 59 x1, and 81306 59 x1. 
 
You asked the Plan to pay for the genetic testing billed. You say that please have a look at the attachment and 
reconsider the charges which were previously denied. The Plan denied your request. The Plan says panel 
testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
May 4, 2023, billed with codes 81225 x1, 81328 59 x1, 81335 x1, 81479 GY 59 x1, 81238 59 x1, 81226 x1, 
81227 59 x1, 81231 59 x1, 81232 59 x1, 81240 59 x1, 81241 59 x1, 81291 59 x1, and 81306 59 x1.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on September 6, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you were in pain and had to get your tooth 
extracted. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service January 17, 2023. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
September 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 5, 2023. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
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 lab services provided on June 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 31, 2023. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says multiple unbundled codes were billed for a single panel. 
 
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 lab services provided on May 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 CDx testing (81479) provided on June 16, 
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 June 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81455) provided on July 26, 2023. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that Next Generation Sequencing (NGS) is covered 
when the patient has not been previously tested with the same test using NGS for the same cancer genetic 
content. 
 
We looked at the file and Medicare rules. The enrollee was previously tested using the Tempus xT test. Based 
on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. 
Therefore, we decided that the Plan does not have to pay for genetic testing (81455) provided on July 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), and a periapical 
radiographic imaging (D0220) provided on July 10, 2023. 
 
You asked the Plan to pay for D0140 and D0220. You say that you do not feel like you should be responsible 
for this amount. The Plan denied your request. The Plan says the rendered dental services are not covered 
benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a limited 
oral evaluation (D0140), and a periapical radiographic imaging (D0220) provided on July 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing (80307, G0483) billed for date of service March 
10, 2023. 
 
You asked the Plan to pay for drug testing. You say that you have billed the services at issue correctly. The 
Plan denied your request. The Plan says the provided records do not support the services billed. 
 
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 80307 and G0483 are not supported in the medical record. Specifically, results for the 
billed testing have not been provided for review. Based on this information, we decided that Medicare rules for 
coverage of drug testing have not been met.  
  Therefore, we decided that the Plan does not have to pay for drug testing (80307, G0483) billed for date of 
service March 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neuromuscular stimulator, electronic shock unit (E0745) 
provided August 16, 2023.  
 
You asked the Plan to pay for the neuromuscular stimulator. You say that please review and reconsider. The 
Plan denied your request. The Plan says neuromuscular stimulation is not covered for chronic low back pain. 
Prior authorization was required for this 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 pay for care from out-of-network providers only in cases involving emergencies, out 
of area urgent care and pre-approved care. 
 
We looked at the file and Medicare rules. The requested provider in this case is not a network provider with the 
Plan. The Plan had network providers available who could have provided the items/services at issue in this 
appeal. The Plan did not pre-approve the item/service at issue. Based on this information, we decided that 
Medicare rules for coverage of the neuromuscular stimulator have not been met. Therefore, we decided that the 
Plan does not have to pay for the neuromuscular stimulator, electronic shock unit (E0745) provided August 16, 
2023.