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

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on March 16, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says The Plan says this is an administrative determination for coding and is not based on 
clinical criteria. The Plan says that Comprehensive Genomic Profile (CGP) testing Guardant-360 requires use 
of CPT 81479, and the appropriate DEX Z identifier entered adjacent in the comment narrative field. 
 
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 claim is missing the main code 
and identifier required by Medicare.  
 
 
 
 
 
 
Based on this information, we decided that Medicare rules for coverage of this claim have not been met. 
Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on March 16, 
2020.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for a chest x-ray (71045) provided on April 30, 2020. 
 
You asked the Plan to pay for the chest x-ray. You say that you would like reconsideration because this service 
is being denied as a duplicate in error. The Plan denied your request. The Plan says that procedure code 71045 
was denied as the column II code to the column I code 71046. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
We find that CPT code 71045 is supported in the record. Specifically, CPT code 71045 was rendered by a 
different provider than who performed the column I procedure. NCCI edits are inappropriate in this case. Based 
on this information, we decided that Medicare rules for coverage of the chest x-ray have been met. Therefore, 
we decided that the Plan has to pay for a chest x-ray (71045) provided on April 30, 2020.  
 
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 pay for Moderate sedation services (99153) excision of maxillary 
torus palatinus (21032) moderate sedation services (99152) provided February 21, 2020. 
 
You asked the Plan to pay for the dental services. You say that this procedure was not related to any difficulties 
with your teeth. You are requesting an appeal of the denial. The Plan denied your request. The Plan says these 
services are not covered under the plan benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 Moderate 
sedation services (99153) excision of maxillary torus palatinus (21032) moderate sedation services (99152) 
provided February 21, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on September 26, 
2018 through March 20, 2019. 
 
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration because 
this was not durable medical equipment and was not mailed to the member. The Plan denied your request. The 
Plan says S codes are not payable by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code S9328 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT 
code S9328 has a status indicator of I. This means the CPT code S9328 is not valid for Medicare purposes. 
Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not 
been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) 
provided on September 26, 2018 through March 20, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that this was not out of 
network as there was no other source available. The Plan denied your request. The Plan says you were charged 
this cost sharing 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 $270 
copayment for each ambulance trip. You had one ambulance trip. The Plan charged you $270 for these 
services. 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 ambulance services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on May 1, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the services provided in a skilled nursing facility. You say that you rely on the 
nursing facility to obtain any needed authorizations. The Plan denied your request. The Plan says the patient 
was at a non-plan nursing home.  Neither you nor the nursing home requested authorization for this non-plan 
care.  The plan says that unauthorized, non-plan 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 requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical services provided on May 1, 2020 by 
an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a therapeutic CGM including supplies 
(K0553) and a receiver for a CGM (K0554) purchased on February 10 and February 11, 2020. 
 
You asked the Plan to waive the coinsurance for a therapeutic CGM and a receiver for a CGM. You say that 
this was erroneously processed as Durable Medical Equipment (DME) and should be processed as diabetic 
supplies with a $0 copayment. The Plan denied your request. The Plan says the correct coinsurance was 
applied. 
 
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 20% 
coinsurance for diabetic monitoring supplies from a diabetic supplier (non-preferred).  
 
You have been asked to pay $101.94, or $49.68 (20% of the billed amount $248.38) plus $52.26 (20% of the 
billed amount $261.29), for a therapeutic CGM and a receiver for a CGM. A therapeutic CGM and a receiver 
for a CGM fall within the "Diabetes self-management training, diabetic 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 coinsurance for a therapeutic CGM including supplies (K0553) and a 
receiver for a CGM (K0554) purchased on February 10 and February 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transitional care management services (99496) provided on 
January 29, 2020. 
 
You asked the Plan to pay for the transitional care management services. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation 
does not support a hospitalization in January 2020 or a transition from an inpatient facility to a home or 
community type setting. 
 
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 99496 is transitional Care Management Services with the 
following required elements: Communication (direct contact, telephone, electronic) with the patient and/or 
caregiver within 2 business days of discharge Medical decision making of high complexity during the service 
period Face-to-face visit, within 7 calendar days of discharge. 
 
We asked our coder 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 transitional care management services. Our reviewer says 
that the documentation does not support Place of Service Code 11, office. Our reviewer found per CPT 
guidelines code 99496 is used to report transitional care management services (TCM).  These services are for a 
new or established patient whose medical and/or psychosocial problems require moderate or high complexity 
medical decision making during transitions in care from an inpatient hospital setting.  (including acute hospital, 
rehabilitation hospital, long term acute care hospital), partial hospital, observation status in a hospital, or skilled 
nursing facility/nursing facility to the patient's community setting (home, domiciliary, rest home, or assisted 
living). 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the transitional care management services have not been met. Therefore, we 
decided that the Plan does not have to pay for transitional care management services (99496) provided on 
January 29, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 molecular pathology genomic profiling 
provided to the enrollee on March 11, 2020. 
 
You asked the Plan to pay for the servcies. You say that this should be paid for. The Plan denied your request. 
The Plan says this should have been reported with CPT 81479. 
 
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare 
rules for coverage of the servcies have not been met. Therefore, we decided that the Plan does not have to pay 
for Guardant360 molecular pathology genomic profiling provided to the enrollee on March 11, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to hold you harmless for a fluid circulating cold pad with a pump (E0218) provided on February 12, 2020 through March 3, 2020.

You asked the Plan to hold you harmless for the cold pad. You say that you would like reconsideration because you were not aware that this equipment would not be covered. The Plan denied your request. The Plan says that this equipment is not medically necessary, but you are not responsible for this payment.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules.

You were referred for the cold pad by a contract provider. The file does not show that the Plan provided notice that the cold pad would not be covered. Under Medicare rules, this means the cold pad is considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for a fluid circulating cold pad with a pump (E0218) provided on February 12, 2020 through March 3, 2020. 

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 pay for a complicated incision and drainage of an abscess (10061) 
provided on November 19, 2019. 
 
You asked the Plan to pay for the incision and drainage. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the documentation submitted does not 
support the service 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. 
 
In this case, the CPT Code Manual definition of code 10061 is incision and drainage of abscess (eg, carbuncle, 
suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or 
multiple. 
 
We find that CPT code 10061 is not supported in the record. Specifically, the record indicates that this 
procedure was simple and without complication. There is a more appropriate CPT code for the service 
rendered. Based on this information, we decided that Medicare rules for coverage of the incision and drainage 
have not been met. Therefore, we decided that the Plan does not have to pay for a complicated incision and 
drainage of an abscess (10061) provided on November 19, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on December 11, 2019. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are 
not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this 
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab 
services provided on December 11, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 panel rendered on April 13, 2020. 
 
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 the Guardant360 panel must be billed with procedure 
code 81479. 
 
The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. 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 Guardant360 panel rendered on April 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services provided on October 31, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these are not covered 
chiropractic services. 
 
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. Therefore, we decided 
that the Plan does not have to pay for the chiropractic services provided on October 31, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided on 
April 18, 2020. 
 
You asked the Plan to pay for genetic testing. You say that the enrollee's treating physician ordered this testing 
to determine if there was a more effective therapy to treat the enrollee. The Plan denied your request. The Plan 
says the denial of payment for this testing is correct, because this testing has not been billed with the 
appropriate coding. 
 
The Plan must follow Medicare rules. Medicare rules say that CGP testing must be billed with CPT code 81479 
for date of service April 18, 2020.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for 
comprehensive genomic profile (CGP) testing provided on April 18, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided from October 6, 2019 through 
October 9, 2019. 
 
You asked the Plan to pay for inpatient services. You say that you sent the claim to the Plan as secondary to 
Medicare. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on October 5, 2019. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for inpatient services 
provided from October 6, 2019 through October 9, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on January 14, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says that the Plan 
requires utilization of network providers when possible and available, and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented. 
 
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 
laboratory 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 laboratory services provided on January 14, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 panel rendered on April 8, 2020. 
 
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 the Guardant360 panel must be billed with procedure 
code 81479. 
 
The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. 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 Guardant360 panel rendered on April 8, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 molecular pathology provided on April 11, 
2020. 
 
You asked the Plan to pay for Guardant360 molecular pathology. You say that you would like reconsideration 
because all of the member's treatment options require molecular testing to determine eligibility. The Plan 
denied your request. The Plan says Medicare requires the use of CPT code 81479 to report a Guardant360 
molecular pathology genomic profiling for NSCLC and an appropriate DEX Z-Code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Guardant360 molecular pathology have not been met. Specifically, per Medicare guidelines, the 
more appropriate CPT code for this pathology is 81479. Additionally, this claim was not submitted with an 
appropriate DEX Z-Code. Therefore, we decided that the Plan does not have to pay for the Guardant360 
molecular pathology provided on April 11, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 panel rendered on April 26, 2020. 
 
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 the Guardant360 panel must be billed with procedure 
code 81479. 
 
The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. 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 Guardant360 panel rendered on April 26, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on February 6, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes cannot 
be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab 
requisition stating exactly which testing was to be performed. 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 the drug testing services provided on February 6, 2020.