Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested behavioral health services. 
 
You asked the Plan to pre-approve the behavioral health services. The Plan denied your request. The Plan says 
you must receive care from in-network providers with the exception of emergency or urgent care, dialysis 
while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, 
which requires prior authorization from the plan. 
 
The Plan must follow Medicare rules. Medicare rules say that a Marriage Family Therapist is not eligible to 
participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue is a Marriage Family Therapist. A Marriage 
Family Therapist is not eligible to participate in the Medicare program. Therefore, we decided that the Plan 
does not have to pre-approve the requested behavioral health services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an orthopedic pillow for the enrollee. 
 
You asked the Plan to pre-approve the pillow. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an orthopedic pillow for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a Skilled Nursing Facility (SNF). 
 
You asked the Plan to pre-approve SNF admission. You say that the enrollee is currently in the hospital and 
you are requesting transfer to the SNF. The Plan denied your request. The Plan says the denial of authorization 
for SNF service is correct. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 SNF admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee does not have daily skilled 
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The 
enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on 
an inpatient basis in a Skilled Nursing Facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a Skilled Nursing Facility (SNF).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on November 21, 2019. 
 
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 November 21, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on February 18, 2020. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be reported with one 
unit of CPT 81479 and the appropriate DEX Z-Code.  
 
We looked at the file and Medicare rules. The requested Guardant360 testing was billed with multiple CPT 
codes. Per the applicable article, this testing must be reported with CPT 81479 and the appropriate DEX Z-
Code. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on February 18, 
2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on February 14, 2020. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be reported with one 
unit of CPT 81479 and the appropriate DEX Z-Code.  
 
We looked at the file and Medicare rules. The requested Guardant360 testing was billed with multiple CPT 
codes. Per the applicable article, this testing must be reported with CPT 81479 and the appropriate DEX Z-
Code. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. 
 Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on February 14, 
2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to 
the enrollee on March 9, 2020. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says Comprehensive Genomic Profile (CGP) testing (Guardant-360? and NEXT-Generation?) 
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. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have to pay 
for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on March 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on January 24, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that you would like reconsideration because the 
provider relies on the facility to verify the member's eligibility. The Plan denied your request. The Plan says the 
provider did not obtain prior authorization and there are in-network providers available. 
 
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 January 24, 2020 
by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network facility for knee surgery. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says knee surgery can be completed at a contracted facility. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a referral to an out-of-network facility for knee surgery.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to 
the enrollee on March 23, 2020. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says Comprehensive Genomic Profile (CGP) testing (Guardant-360? and NEXT-Generation?) 
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. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have to pay 
for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on March 23, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a refill kit for your implantable infusion pump (HCPCS 
A4220) provided to the enrollee on January 22, 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 the cost of this service is included in the payment for the device and medication. 
 
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 HCPCS 
code A4220 has a bundled relationship with HCPCS code J1170 and CPT 62370 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 a refill kit for your implantable 
infusion pump (HCPCS A4220) provided to the enrollee on January 22, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided to the enrollee from August 
8, 2019 to October 7, 2019. 
 
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 the provider has been informed that this service was billed incorrectly. 
 
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 denied CPT codes 86580, 36415, 90792, 90837 is not supported in the medical record. 
Specifically, the revenue code does not match the Place of Treatment on the claim. 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 psychotherapy services provided to the enrollee from August 8, 2019 to October 
7, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy (HCPCS S9328) provided to the 
enrollee from April 9, 2019 to May 21, 2019. 
 
You asked the Plan to pay for the therapy. You say that this should be paid for. The Plan denied your request. 
The Plan says Original Medicare does not allow payment for this procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that HCPCS code S9328 is not supported in the medical record. Specifically, this code has a status 
indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for 
Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the therapy have 
not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (HCPCS 
S9328) provided to the enrollee from April 9, 2019 to May 21, 2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for SNF care from January 1, 2020 through 
January 31, 2020. 
 
You asked the Plan to waive the copayment for SNF care. You say that you believe your cost-share should be 
$0 because you did not use all 20 days. The Plan denied your request. The Plan says the claim was processed 
accordingly with your 2020 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file shows the enrollee has been in the same benefit period since October 24, 2019 through 
January 31, 2020. You were applied a rate of a $176 copayment per day for days 54-84 during your stay. Your 
2020 Summary of Benefits says the 2020 rates for SNF care: enrollees must pay a $0 copayment per day: for 
days 1-20 and a $176 copayment per days, for days 21-100 for SNF care. Your EOC states, "a benefit period 
begins on the first day you go to a Medicare-covered inpatient hospital or a skilled nursing facility. The benefit 
period ends when you haven't been an inpatient at any hospital or SNF for 60 days in a row. If you go to the 
hospital (or SNF) after one benefit period has ended. There is no limit to the number of benefit periods you can 
have." 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 SNF care from January 1, 2020 through 
January 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient surgery provided on March 
2, 2020. 
 
You asked the Plan to waive the copayment for the outpatient surgery. You say that you feel you should not be 
responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied 
your request. The Plan says you received outpatient surgery provided in an outpatient hospital facility on the 
date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract 
with the Plan. 
 
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 $360 
copayment for Outpatient surgery.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received outpatient 
surgery provided in an outpatient hospital facility on March 2, 2020. You have been asked to pay a $360 
copayment for the outpatient surgery. The outpatient surgery 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 March 2, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services provided on March 4, 2020. 
 
You asked the Plan to pay for the outpatient services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
 
We looked at the file and Medicare rules. The procedure codes submitted in this case denied per OCE Edit 10. 
The claim submitted the condition code 21. Therefore, we decided that the Plan does not have to pay for the 
outpatient services provided on March 4, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a Skilled Nursing Facility (SNF). 
 
You asked the Plan to pre-approve SNF admission. You say that the enrollee is now medically stable and able 
to be transferred to the SNF. The Plan denied your request. The Plan says the denial of authorization for SNF 
service is correct. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 SNF admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee does not have daily skilled 
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The 
enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on 
an inpatient basis in a Skilled Nursing Facility (SNF) setting. 
 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a Skilled Nursing Facility (SNF).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance transport (A0429, A0425) 
provided July 10, 2018. 
 
You asked the Plan to waive the copayment for the ambulance transport. You say that the copayment should be 
waived. 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 $100 
copayment for Ambulance Services.  
 
You have been asked to pay a $100 copayment for the ambulance transport. The ambulance transport 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. Therefore, we decided that the Plan does not have to waive the copayment for 
an ambulance transport (A0429, A0425) provided July 10, 2018.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a special back implant for the enrollee. 
 
You asked the Plan to pre-approve the implant. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is considered experimental and investigational. 
 
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 implant. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the implant remains experimental in spinal surgery for stenosis. More research is needed to show safety 
and efficacy. 
 
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 implant have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a special back implant for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (S9328) provided from December 6, 2018, to 
January 17, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee 
Schedule indicates that the code in question is not valid for Medicare purposes.  
 
We looked at the file and Medicare rules. Code S9328 is assigned a status indicator of under the Physician 
Fee Schedule, which means that this code is not valid for Medicare purposes. Medicare uses another code for 
reporting of, and payment for, these services. 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 
services (S9328) provided from December 6, 2018, to January 17, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery on May 13, 2020.
You asked the Plan to waive the copayment for an outpatient surgery. You say that you believe the inpatient
copay would be more correct because you stayed overnight. The Plan denied your request. The Plan says the
copayment you are being charged is correct.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $600
copayment for per visit for each in-network outpatient surgery, including services provided at hospital
outpatient facilities and ambulatory surgical centers. Your contract with the Plan also clearly says that unless
the provider writes an order to admit you as an inpatient to the hospital, you are an outpatient and pay the costsharing
amounts for outpatient surgery.
You were not admitted to the hospital under inpatient care, therefore the $600 copayment for an outpatient
surgery applies to this claim. An outpatient surgery falls within the outpatient surgery, including services
provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan
does not have to waive the copayment for an outpatient surgery on May 13, 2020.