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

 
We decided that the Plan does not have to pay for genetic testing services provided to the enrollee on January 
8, 2020. 
 
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 there was no authorization for these services. 
 
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 genetic testing services provided to the enrollee on 
January 8, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on February 6, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for laboratory testing. You say that your facility does not accept walk-ins and does 
not have access to the enrollee's insurance requirements, limitations, or conditions. The Plan denied your 
request. The Plan says the denial of payment for this testing is correct, because this provider is out-of-network 
with the Plan and the ordering provider is also out-of-network with the Plan. 
 
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 February 6, 2020 
by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant-360 testing provided on April 10, 2020. 
 
You asked the Plan to pay for the Guardant-360 testing. You say that you would like reconsideration because 
the testing services were medically necessary. The Plan denied your request. The Plan says CGP testing (i.e. 
Guardant-360 and NEXT-Generation) requires use of CPT 81479 (for the entire multi-test panel), and the 
appropriate DEX Z identifier entered adjacent in the comment narrative field. 
 
The Plan must follow Medicare rules. Medicare rules say that to report a CGP service, test providers should use 
CPT code 81479 at this time, in addition to the approved DEX Z-CodeTM for the test. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Guardant-360 testing have not been met. Specifically, there is a more appropriate CPT code, 
81479, to describe the service provided. Therefore, we decided that the Plan does not have to pay for Guardant-
360 testing provided on April 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on June 22, 2020. 
 
You asked the Plan to pay for the domiciliary or rest home visit. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 
services at issue. 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 a domiciliary or rest home visit provided on June 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete maxillary denture provided on March 4, 2020. 
 
You asked the Plan to pay for the complete maxillary denture. You say that you confirmed with the provider 
and the Plan that both upper and lower dentures were covered. You also say that you live on a fixed income, 
and cannot afford the denture if it is not entirely covered by your insurance. The Plan denied your request. The 
Plan says the maximum benefit of $1,000 has been reached. 
 
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 Plan offers a $1,000 annual dental 
benefit maximum. The record shows that you met the annual maximum benefit while processing this claim for 
the March 4, 2020 date of service, and your annual maximum benefit has been exhausted. Therefore, we 
decided that the Plan does not have to pay for the complete maxillary denture provided on March 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99307) and nail 
debridement provided on February 6, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the subsequent nursing facility care and nail debridement. You say that the 
enrollee is a resident in a nursing home and has an authorization on file for all care at the facility including 
consultations. The Plan denied your request. The Plan says enrollee's must receive their medical services from 
an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-
contracted providers require prior authorization before services being rendered. 
 
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 subsequent nursing facility care (99307) and 
nail debridement provided on February 6, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia service provided on March 23, 2020. 
 
You asked the Plan to pay for Anesthesia for diagnostic or therapeutic nerve blocks and injections (when block 
or injection is performed by a different physician or other qualified health care professional); prone position 
(01992). You say that the Plan should pay this claim. The Plan denied your request. The Plan says CPT code 
62323 was submitted for this service and the two codes cannot be billed together. 
 
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 
Anesthesia for diagnostic or therapeutic nerve blocks and injections (when block or injection is performed by a 
different physician or other qualified health care professional); prone position (01992) has a bundled 
relationship with code 62323 and cannot be paid as billed. This code cannot be paid as a separate line item. 
Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan 
does not have to pay for the anesthesia service provided on March 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided from February 4, 2020 through 
February 27, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that the claims should be paid. The Plan denied 
your request. The Plan says prior authorization was not obtained by the provider or facility. The Plan states the 
provider should have verified the member's eligibility, health benefits and obtained authorization prior to the 
member's visit before providing services to the member as outlined on the member's ID card. 
 
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 from February 4, 
2020 through February 27, 2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided to the enrollee on February 
24, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says that the patient could have been safely transported by another type 
of motor vehicle. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance services. Our reviewer says 
that the ambulance services were not medically reasonable and necessary for the enrollee in this case. The 
documentation did not support that other means of transport (such as stretcher van, wheelchair van, taxi, private 
car, or other type of vehicle) were contraindicated for this patient. The documentation did not support that the 
patient needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped 
ambulance can provide for safe transport. Our physician reviewer found that the enrollee's condition did not 
meet Medicare criteria for the ambulance services. 
 
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 ambulance services have not been met. Therefore, we decided that the Plan 
does not have to pay for the ambulance services provided to the enrollee on February 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 testing provided on April 8, 2020. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like reconsideration because 
this testing is medically necessary. The Plan denied your request. The Plan says there is a more appropriate 
code to describe the services provided. 
 
The Plan must follow Medicare rules. Medicare rules say that to report a CGP service, test providers should use 
CPT code 81479 at this time. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Guardant360 testing have not been met. Specifically, there is a more appropriate code, 81479, 
to describe the services provided. Therefore, we decided that the Plan does not have to pay for Guardant360 
testing provided on April 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 testing provided on May 1, 2020. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like reconsideration because 
the testing was medically necessary. The Plan denied your request. The Plan says there is a more appropriate 
code to describe the services provided. 
 
The Plan must follow Medicare rules. Medicare rules say that laboratories with 1 to 4 gene(s) on their targeted 
NGS panel should use CPT? 81479 and one (1) UOS along with their test identifier (DEX Z-CodeTM) to 
represent this service on their claims. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Guardant360 testing have not been met. Specifically, Guardant360 should be reported with the 
more appropriate CPT code, 81479. Therefore, we decided that the Plan does not have to pay for Guardant360 
testing provided on May 1, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on November 27, 2019. 
 
You asked the Plan to pay for the ambulance services. You say that this should be covered with your 
deductible. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on November 27, 2019. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on November 27, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for ambulance services provided from April 
11, 2020 to May 18, 2020. 
 
You asked the Plan to waive the copayments for ambulance services. You say that you disagree with the 
charges because the enrollee was not in their right mind and insisted on going by ambulance even though there 
was nothing physically wrong. The Plan denied your request. The Plan says the claims were processed 
correctly and the enrollee is being charged the correct 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). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $395 copayment for ground ambulance services.  
 
The enrollee received ambulance services from April 11, 2020 to May 18, 2020 for a total of 4 services. 
Therefore, the enrollee is responsible to pay a $395 copayment per each service. The total amount they owe is: 
$395 (copayment) x 4 (ambulance services) = $1,580. 
 
The enrollee has been asked to pay the total copayment amount of $1,580 for ambulance services. Ambulance 
services fall within the ground transportation benefit category. This means that the enrollee has been asked to 
pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the 
enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayments for ambulance services provided from April 11, 2020 to May 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar sacral orthosis provided to the enrollee on March 
30, 2020. 
 
You asked the Plan to pay for the orthosis. You say that this was medically necessary. The Plan denied your 
request. The Plan says that none of the medical records provided show or mention an order for a back brace. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order which support medical necessity for the supplies provided 
in this case. The physician order is not signed by the ordering physician. The record shows that the Plan made 
several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan 
does not have to pay for the lumbar sacral orthosis provided to the enrollee on March 30, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on April 10, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 April 10, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 test provided to the enrollee on May 5, 
2020. 
 
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 Medicare requires use of CPT 81479 to report a Guardant360? molecular pathology genomic 
profiling for NSCLC. 
 
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 services have not been met. Therefore, we decided that the Plan does not have to pay 
for the Guardant360 test provided to the enrollee on May 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on 
January 23, 2020. 
 
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you have been a 
patient of this provider for over 20 years and the services have been paid. The Plan denied your request. The 
Plan says the treating provider opted out of Medicare effective February 19, 2016 to February 19, 2022. The 
Plan also says that your plan does not cover services performed by a privately contracted provider. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
the periodic oral evaluation and prophylaxis provided on January 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from January 12 
to January 22, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you disagree with this 
copayment. The Plan denied your request. The Plan says the correct copayment 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 a $393 
copayment for days 1-5 per admission for inpatient hospital care.  
 
You have been asked to pay $1,965, or a $393 copayment for days 1-5, for an inpatient hospital stay. An 
inpatient hospital stay 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. Therefore, we decided that the Plan does not have 
to waive the copayment for an inpatient hospital stay from January 12 to January 22, 2020.  

We read your letter and knows that you may have a quality of care concern. We cannot address quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement Organization for further review.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 testing provided on May 5, 2020. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like reconsideration because 
this testing was medically necessary. The Plan denied your request. The Plan says there is a more appropriate 
code to describe the services provided. 
 
The Plan must follow Medicare rules. Medicare rules say that laboratories with 1 to 4 gene(s) on their targeted 
NGS panel should use CPT? 81479 and one (1) UOS along with their test identifier (DEX Z-CodeTM) to 
represent this service on their claims. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to 
pay for Guardant360 testing provided on May 5, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient mental health services provided from March 5, 
2020 through March 26, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the outpatient mental health services. You say that you requested an appeal for 
coverage of these services but you did not provide an argument for coverage. The Plan denied your request. 
The Plan says 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 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. 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 outpatient mental health services provided 
from March 5, 2020 through March 26, 2020 by an out of network (OON) provider.